Healthcare Provider Details

I. General information

NPI: 1659371565
Provider Name (Legal Business Name): MRC PINECREST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 09/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 TOME TEMPLE DR
LUFKIN TX
75904-5550
US

IV. Provider business mailing address

1302 TOM TEMPLE DR
LUFKIN TX
75904-5550
US

V. Phone/Fax

Practice location:
  • Phone: 936-634-1054
  • Fax: 936-634-1054
Mailing address:
  • Phone: 936-634-1054
  • Fax: 936-634-1056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number116427
License Number StateTX

VIII. Authorized Official

Name: MS. DEVON COX
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 281-210-0123