MEDICARE: PROVIDER HEALTHCARE SERVICES OF CONCHO LP

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	113535	TX

General Provider Information

NPI Number	:	1710989595
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDER HEALTHCARE SERVICES OF CONCHO LP

Provider Business Mailing Address
First Line	:	PO BOX 838
Second Line	:	613 EAKER ST
City	:	EDEN
State	:	TX
Zip	:	76837-0838
Country	:	US
Telephone Number	:	325-869-5531
Fax Number	:	325-869-5152

Provider Business Practice Location Address
First Line	:	613 EAKER ST
Second Line	:
City	:	EDEN
State	:	TX
Zip	:	76837
Country	:	US
Telephone Number	:	325-869-5531
Fax Number	:	325-869-5152

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	IRVIN DOUGLAS STRECKERT
Credential	:
Telephone Number	:	325-869-5531

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	08/22/2020

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