Provider Demographics
NPI:1538169453
Name:INTEGRATED HEALTH SERVICES AT HANOVER HOUSE INC
Entity type:Organization
Organization Name:INTEGRATED HEALTH SERVICES AT HANOVER HOUSE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-513-8738
Mailing Address - Street 1:1600 MURCHISON DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-2828
Mailing Address - Country:US
Mailing Address - Phone:915-544-2002
Mailing Address - Fax:915-544-0696
Practice Address - Street 1:1600 MURCHISON DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-2828
Practice Address - Country:US
Practice Address - Phone:915-544-2002
Practice Address - Fax:915-544-0696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX134366314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1000665Medicaid
TX004791Medicaid
TX455471Medicare ID - Type UnspecifiedPROVIDER NUMBER