Healthcare Provider Details

I. General information

NPI: 1740653633
Provider Name (Legal Business Name): PITTSBURG SENIOR CARE, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 11/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6813 CACTUS DR
WACO TX
76712-6742
US

IV. Provider business mailing address

6813 CACTUS DR
WACO TX
76712-6742
US

V. Phone/Fax

Practice location:
  • Phone: 254-399-6788
  • Fax: 254-772-1110
Mailing address:
  • Phone: 254-399-6788
  • Fax: 254-772-1110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number136170
License Number StateTX

VIII. Authorized Official

Name: MICHAEL BUMPASS
Title or Position: MEMBER
Credential:
Phone: 254-399-6788