Provider Demographics
NPI:1386936664
Name:MSHC BONNER STREET PLAZA LLC
Entity type:Organization
Organization Name:MSHC BONNER STREET PLAZA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:POWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-792-0838
Mailing Address - Street 1:421 BONNER STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-2330
Mailing Address - Country:US
Mailing Address - Phone:903-586-9871
Mailing Address - Fax:
Practice Address - Street 1:421 S BONNER ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-2330
Practice Address - Country:US
Practice Address - Phone:903-586-9871
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-05
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX129146314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX005275Medicaid
TX676092Medicare PIN