Basic Information
| Provider Information | |||||||||
| NPI: | 1063858298 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CROCKETT SENIOR CARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PITTSBURG NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 W STATE HIGHWAY 6 | ||||||||
| Address2: | SUITE 612 | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767127923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543996788 | ||||||||
| FaxNumber: | 2543996766 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 W STATE HWY 6 | ||||||||
| Address2: | SUITE 612 | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543996788 | ||||||||
| FaxNumber: | 2543996766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2013 | ||||||||
| LastUpdateDate: | 04/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2543996788 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001021232 | 05 | TX | MEDICAID |