MEDICARE: PM MANAGEMENT-PORTLAND NC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	120859	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	5391	OTHER	TX	FACILITY ID NO.

General Provider Information

NPI Number	:	1578509584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PM MANAGEMENT-PORTLAND NC, LLC

Provider Business Mailing Address
First Line	:	600 N PEARL ST STE 1050
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75201-7495
Country	:	US
Telephone Number	:	214-252-7600
Fax Number	:	214-252-7704

Provider Business Practice Location Address
First Line	:	221 CEDAR DR
Second Line	:
City	:	PORTLAND
State	:	TX
Zip	:	78374-2900
Country	:	US
Telephone Number	:	361-643-1888
Fax Number	:	361-777-3419

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MICHAEL BEAL
Credential	:
Telephone Number	:	214-252-7600

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	03/04/2020

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