=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659371565
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MRC PINECREST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2005
-----------------------------------------------------
Last Update Date | 09/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1302 TOME TEMPLE DR
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75904-5550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-634-1054
-----------------------------------------------------
Fax | 936-634-1054
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1302 TOM TEMPLE DR
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75904-5550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-634-1054
-----------------------------------------------------
Fax | 936-634-1056
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING SUPERVISOR
-----------------------------------------------------
Name | MS. DEVON COX
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-210-0123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 116427
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------