Basic Information
| Provider Information | |||||||||
| NPI: | 1154850329 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PASADENA SENIOR CARE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | VISTA NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6500 HORIZON CIR | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767126985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543996788 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4300 VISTA RD | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775042118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7139466787 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2017 | ||||||||
| LastUpdateDate: | 06/09/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2543996788 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PASADENA SENIOR CARE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.