Provider Demographics
NPI:1316938145
Name:TEXAS - WAVERLEY GROUP, INC.
Entity type:Organization
Organization Name:TEXAS - WAVERLEY GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY / TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAUNCEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:DUNBAR
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:601-956-1576
Mailing Address - Street 1:1108 W KILPATRICK ST
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-7477
Mailing Address - Country:US
Mailing Address - Phone:817-645-3931
Mailing Address - Fax:
Practice Address - Street 1:1108 W KILPATRICK ST
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-7477
Practice Address - Country:US
Practice Address - Phone:817-645-3931
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TEXAS-WAVERLEY GROUP,INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-01
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112008314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
455665Medicare Oscar/Certification