1891097432 NPI number — PM MANAGEMENT CORSICANA NC II LLC

Table of content: (NPI 1891097432)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891097432 NPI number — PM MANAGEMENT CORSICANA NC II LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PM MANAGEMENT CORSICANA NC II 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:
HERITAGE OAKS RETIREMENT VILLAGE
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:
1891097432
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2020
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:
3002 W 2ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORSICANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75110-2492
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-872-1530
Provider Business Practice Location Address Fax Number:
903-872-5949
Provider Enumeration Date:
12/02/2010

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: 310400000X , with the licence number:  132227 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 131490 , 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: 005357 . This is a "FACILITY ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 001019214 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com