Provider Demographics
NPI:1184627093
Name:BURLESON ST. JOSEPH MANOR
Entity type:Organization
Organization Name:BURLESON ST. JOSEPH MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:COTTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:LNFA
Authorized Official - Phone:979-567-0920
Mailing Address - Street 1:1022 PRESIDENTIAL CORRIDOR EAST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:TX
Mailing Address - Zip Code:77836-4611
Mailing Address - Country:US
Mailing Address - Phone:979-567-0920
Mailing Address - Fax:979-567-4811
Practice Address - Street 1:1022 PRESIDENTIAL CORRIDOR EAST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:TX
Practice Address - Zip Code:77836-4611
Practice Address - Country:US
Practice Address - Phone:979-567-0920
Practice Address - Fax:979-567-4811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107880313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001000513Medicaid
TXD86907Medicare UPIN
TX001000513Medicaid
TXB26698Medicare UPIN
TXG58306Medicare UPIN