Provider Demographics
NPI:1386726396
Name:ST. DOMINIC VILLAGE
Entity type:Organization
Organization Name:ST. DOMINIC VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GRADY
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-741-8736
Mailing Address - Street 1:2409 HOLCOMBE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77021-2023
Mailing Address - Country:US
Mailing Address - Phone:713-741-8701
Mailing Address - Fax:713-741-9811
Practice Address - Street 1:2409 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77021-2023
Practice Address - Country:US
Practice Address - Phone:713-741-8701
Practice Address - Fax:713-741-9811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114382313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility