Healthcare Provider Details

I. General information

NPI: 1790834323
Provider Name (Legal Business Name): ANNADALE MANOR, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 09/02/2025
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10702 COUNTY ROAD 1300
WOLFFORTH TX
79382-7006
US

IV. Provider business mailing address

PO BOX 65725
LUBBOCK TX
79464-5681
US

V. Phone/Fax

Practice location:
  • Phone: 806-866-9186
  • Fax:
Mailing address:
  • Phone: 806-441-7798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. TONI JENNINGS
Title or Position: ADMINISTRATOR
Credential:
Phone: 806-441-7798