MEDICARE: KRISTI LEE MANOR 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	314000000X	Skilled Nursing Facility	676027	TX
2	313M00000X	Nursing Facility/Intermediate Care Facility	111707	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	:	1558472951
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KRISTI LEE MANOR INC

Provider Business Mailing Address
First Line	:	1941 CHESTNUT ST
Second Line	:
City	:	COLORADO CITY
State	:	TX
Zip	:	79512-3099
Country	:	US
Telephone Number	:	325-728-5247
Fax Number	:	325-728-2611

Provider Business Practice Location Address
First Line	:	1941 CHESTNUT ST
Second Line	:
City	:	COLORADO CITY
State	:	TX
Zip	:	79512-3099
Country	:	US
Telephone Number	:	325-728-5247
Fax Number	:	325-728-2611

Authorized Official
Title or Position	:	ADMINISTRATOR OWNER
Name	:	MR. CLARK MOODY
Credential	:
Telephone Number	:	325-728-5247

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	04/12/2010

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