1205996832 NPI number — PM MANAGEMENT-TEMPLE NC II LLC

Table of content: (NPI 1205996832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205996832 NPI number — PM MANAGEMENT-TEMPLE NC II LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PM MANAGEMENT-TEMPLE 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:
Provider Other Organization Name Type Code:
6
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:
1205996832
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1703 W. FIFTH ST
Provider Second Line Business Mailing Address:
SUITE 700
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78703-4895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-634-4900
Provider Business Mailing Address Fax Number:
512-634-4950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
512 DRAPER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76504-2911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-771-3062
Provider Business Practice Location Address Fax Number:
254-771-2907
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LITTLE
Authorized Official First Name:
LEW
Authorized Official Middle Name:
N
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
512-634-4900

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  124666 , 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: 001004738 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 005268 . This is a "FACILITY ID NO." identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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