=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104986041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PM MANAGEMENT-SAN ANGELO NC II LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2006
-----------------------------------------------------
Last Update Date | 08/28/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3745 SUMMER CREST DR
-----------------------------------------------------
City | SAN ANGELO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76901-9782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-947-8776
-----------------------------------------------------
Fax | 325-224-2666
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1703 W. FIFTH ST SUITE 700
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-634-4900
-----------------------------------------------------
Fax | 512-634-4950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | LEW N LITTLE JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 512-634-4900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 123446
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------