MEDICARE: TWENTY TWO PACK MANAGEMENT CORP.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	119488	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11948	OTHER	TX	ASSISTED LIVING FACILITY

General Provider Information

NPI Number	:	1497965495
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TWENTY TWO PACK MANAGEMENT CORP.

Provider Business Mailing Address
First Line	:	3000 MIDWAY RD
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-6121
Country	:	US
Telephone Number	:	972-473-7400
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 MIDWAY RD
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-6121
Country	:	US
Telephone Number	:	972-473-7400
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	CHUCK OLSON
Credential	:
Telephone Number	:	972-473-7400

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	08/22/2020

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