Healthcare Provider Details

I. General information

NPI: 1083919856
Provider Name (Legal Business Name): PM MANAGEMENT - KILLEEN IV NC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 08/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 W AVE B
COPPERAS COVE TX
76522-1553
US

IV. Provider business mailing address

1703 W 5TH ST SUITE 700
AUSTIN TX
78703-4893
US

V. Phone/Fax

Practice location:
  • Phone: 254-547-1033
  • Fax: 254-542-3506
Mailing address:
  • Phone: 512-634-4900
  • Fax: 512-634-4966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number131729
License Number StateTX

VIII. Authorized Official

Name: LEW N LITTLE JR.
Title or Position: MANAGER
Credential:
Phone: 512-634-4900