MEDICARE: PM MANAGEMENT-SAN ANGELO NC I 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	128894	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000170	OTHER	TX	FACILITY ID NO.
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972663813
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PM MANAGEMENT-SAN ANGELO NC I LLC

Provider Business Mailing Address
First Line	:	1703 W. FIFTH ST
Second Line	:	SUITE 700
City	:	AUSTIN
State	:	TX
Zip	:	78703
Country	:	US
Telephone Number	:	512-634-4900
Fax Number	:	512-634-4950

Provider Business Practice Location Address
First Line	:	4343 OAK GROVE BLVD
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76904-4550
Country	:	US
Telephone Number	:	325-949-2559
Fax Number	:	325-949-3598

Authorized Official
Title or Position	:	CEO
Name	:	LEW N LITTLE JR.
Credential	:
Telephone Number	:	512-634-4900

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	08/31/2011

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