=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992098099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALVERT SENIOR SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2011
-----------------------------------------------------
Last Update Date | 05/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 E BROWNING ST
-----------------------------------------------------
City | CALVERT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77837-7593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-364-2391
-----------------------------------------------------
Fax | 979-364-2798
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 159
-----------------------------------------------------
City | CALVERT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77837-0159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-364-2391
-----------------------------------------------------
Fax | 979-364-2798
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MR. ALAN DUANE PETERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-919-7495
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 004365
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------