MEDICARE: LA HACIENDA NURSING HOME, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	112118	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336135185
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA HACIENDA NURSING HOME, INC.

Provider Business Mailing Address
First Line	:	4410 HIGHWAY 44
Second Line	:
City	:	SAN DIEGO
State	:	TX
Zip	:	78384-4516
Country	:	US
Telephone Number	:	361-279-3860
Fax Number	:	361-279-3687

Provider Business Practice Location Address
First Line	:	4410 HIGHWAY 44
Second Line	:
City	:	SAN DIEGO
State	:	TX
Zip	:	78384-4516
Country	:	US
Telephone Number	:	361-279-3860
Fax Number	:	361-279-3687

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. JAMES M BAKER JR.
Credential	:
Telephone Number	:	361-279-3860

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	08/22/2020

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