MEDICARE: WT MANOR LP

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	314000000X	Skilled Nursing Facility	111344	TX

General Provider Information

NPI Number	:	1396787834
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WT MANOR LP

Provider Business Mailing Address
First Line	:	3001 WESTWARD DR
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75964-1232
Country	:	US
Telephone Number	:	936-569-2631
Fax Number	:	936-569-0590

Provider Business Practice Location Address
First Line	:	3001 WESTWARD DR
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75964-1232
Country	:	US
Telephone Number	:	936-569-2631
Fax Number	:	936-569-0590

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MICHAEL HENRY MARTEL
Credential	:
Telephone Number	:	210-545-6320

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	08/22/2020

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