=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104986645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PM MANAGEMENT-GEORGETOWN NC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 03/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 FM 971
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78626-4546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-868-6200
-----------------------------------------------------
Fax | 512-869-4180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 N PEARL ST STE 1050
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75201-7495
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-252-7600
-----------------------------------------------------
Fax | 214-252-7704
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MICHAEL BEAL JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-252-7600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 122659
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------