Provider Demographics
NPI:1891885943
Name:THREE RIVERS NURSING HOME, LLC
Entity type:Organization
Organization Name:THREE RIVERS NURSING HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:VIDRINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-786-2256
Mailing Address - Street 1:1717 45TH ST.
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:TX
Mailing Address - Zip Code:78071-2649
Mailing Address - Country:US
Mailing Address - Phone:361-786-2256
Mailing Address - Fax:361-786-2456
Practice Address - Street 1:1717 45TH ST.
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:TX
Practice Address - Zip Code:78071-2649
Practice Address - Country:US
Practice Address - Phone:361-786-2256
Practice Address - Fax:361-786-2456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112944314000000X
TX131278314000000X
TX136010314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001012235Medicaid
TX001012235Medicaid