1306881495 NPI number — PM MANAGEMENT-CORPUS CHRISTI NC III, LLC

Table of content: (NPI 1306881495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306881495 NPI number — PM MANAGEMENT-CORPUS CHRISTI NC III, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PM MANAGEMENT-CORPUS CHRISTI NC III, 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:
TRISUN CARE CENTER-WESTWOOD
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:
1306881495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 N PEARL ST STE 1050
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75201-7495
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-252-7600
Provider Business Mailing Address Fax Number:
214-252-7704

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 CANTWELL LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78408-2605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-882-4284
Provider Business Practice Location Address Fax Number:
361-882-6218
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BEAL
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
214-252-7600

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  127204 , 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: 001014380 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5006 . This is a "FACILITY ID NO." identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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