=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730150657
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MISSIONARY BAPTIST FOUNDATION OF AMERICA, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1003 LOOP RD
-----------------------------------------------------
City | ALPINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79830-3229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-837-3343
-----------------------------------------------------
Fax | 806-837-7076
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1212 13TH ST SUITE 100
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79401-3940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-747-3447
-----------------------------------------------------
Fax | 806-747-1632
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | SARAH B RICE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 806-747-3447
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 15657
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------