=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801221338
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDRESS COUNTY HOSPITAL DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2013
-----------------------------------------------------
Last Update Date | 09/03/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1504 W KENTUCKY AVE
-----------------------------------------------------
City | PAMPA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79065-3916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-665-5746
-----------------------------------------------------
Fax | 806-665-6220
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1504 W KENTUCKY AVE
-----------------------------------------------------
City | PAMPA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79065-3916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-665-5746
-----------------------------------------------------
Fax | 806-665-6220
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. JOHN M HENDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 940-567-6633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------