1700111754 NPI number — PECAN VALLEY HEALTHCARE LLC

Table of content: (NPI 1700111754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700111754 NPI number — PECAN VALLEY HEALTHCARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PECAN VALLEY HEALTHCARE 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:
PECAN VALLEY REHABILITATION AND HEALTHCARE 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:
1700111754
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8000 IH 10 W
Provider Second Line Business Mailing Address:
SUITE 1500
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78230-3802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-525-7993
Provider Business Mailing Address Fax Number:
210-525-7992

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3838 E SOUTHCROSS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78222-3556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-525-7993
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/08/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CRANK
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
210-525-7993

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  129441 , 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: 104259 . This is a "FACILITY ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 001017939 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com