=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598751166
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDEPENDENT ORDER OF ODD FELLOWS GRAND LODGE 100F OF TEXAS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2005
-----------------------------------------------------
Last Update Date | 02/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2300 S OAK GROVE RD
-----------------------------------------------------
City | ENNIS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75119-6841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-875-8643
-----------------------------------------------------
Fax | 972-875-1179
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2300 S OAK GROVE RD
-----------------------------------------------------
City | ENNIS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75119-6841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-875-8643
-----------------------------------------------------
Fax | 972-875-1179
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GRAND SECRETARY
-----------------------------------------------------
Name | JAMES M CURTIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-872-7438
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 114389
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------