MEDICARE: COUNTY OF KENT

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	111179	TX
2	314000000X	Skilled Nursing Facility

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	:	1477507374
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTY OF KENT

Provider Business Mailing Address
First Line	:	1443 NORTH MAIN STREET
Second Line	:	P.O. BOX 86
City	:	JAYTON
State	:	TX
Zip	:	79528-0086
Country	:	US
Telephone Number	:	806-237-3036
Fax Number	:	806-237-2090

Provider Business Practice Location Address
First Line	:	1443 NORTH MAIN STREET
Second Line	:
City	:	JAYTON
State	:	TX
Zip	:	79528-0086
Country	:	US
Telephone Number	:	806-237-3036
Fax Number	:	806-237-2090

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JORDAN MOELLER
Credential	:
Telephone Number	:	806-237-3036

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	12/14/2021

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Directions to “COUNTY OF KENT ” Practice Location

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