=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932112554
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. JOSEPH MANOR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2006
-----------------------------------------------------
Last Update Date | 04/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2333 MANOR DRIVE
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-1907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-821-7330
-----------------------------------------------------
Fax | 979-821-7301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2333 MANOR DRIVE
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-1907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-821-7330
-----------------------------------------------------
Fax | 979-821-7301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR/ADMINISTRATOR
-----------------------------------------------------
Name | MR. HAROLD COTTRELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 979-821-7330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 114596
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------