=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336135185
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LA HACIENDA NURSING HOME, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4410 HIGHWAY 44
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78384-4516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-279-3860
-----------------------------------------------------
Fax | 361-279-3687
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4410 HIGHWAY 44
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78384-4516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-279-3860
-----------------------------------------------------
Fax | 361-279-3687
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. JAMES M BAKER JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 361-279-3860
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 112118
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------