1336209964 NPI number — PM MANAGEMENT-TEMPLE NC III LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336209964 NPI number — PM MANAGEMENT-TEMPLE NC III LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PM MANAGEMENT-TEMPLE 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:
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:
1336209964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2009
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
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:
1700 MARLANDWOOD RD
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:
76502-2842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-773-1591
Provider Business Practice Location Address Fax Number:
254-773-2922
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:  124456 , 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: 004785 . This is a "FACILITY ID NO." identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 001004739 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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