1063858298 NPI number — CROCKETT SENIOR CARE, LLC

Table of content: (NPI 1063858298)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063858298 NPI number — CROCKETT SENIOR CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROCKETT SENIOR CARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PITTSBURG NURSING CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063858298
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 W STATE HIGHWAY 6
Provider Second Line Business Mailing Address:
SUITE 612
Provider Business Mailing Address City Name:
WACO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76712-7923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-399-6788
Provider Business Mailing Address Fax Number:
254-399-6766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 W STATE HWY 6
Provider Second Line Business Practice Location Address:
SUITE 612
Provider Business Practice Location Address City Name:
WACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-399-6788
Provider Business Practice Location Address Fax Number:
254-399-6766
Provider Enumeration Date:
05/15/2013

Additional Information

Authorized Official

Authorized Official Last Name:
COOK
Authorized Official First Name:
JACK
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
254-399-6788

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001021232 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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