=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376306944
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALLINGER MEMORIAL HOSPITAL DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2024
-----------------------------------------------------
Last Update Date | 02/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2210 HOWARD STREET
-----------------------------------------------------
City | SAN ANGELO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76901-1318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-944-0561
-----------------------------------------------------
Fax | 325-944-0562
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4150 INTERNATIONAL PLAZA SUITE 200
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76109-4875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-348-8959
-----------------------------------------------------
Fax | 817-348-0466
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MR. RHETT FRICKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 325-365-2531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------