Basic Information
| Provider Information | |||||||||
| NPI: | 1245390780 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PM MANAGEMENT-CORPUS CHRISTI NC LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TRISUN CARE CENTER CORPUS CHRISTI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1703 W. FIFTH ST | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5126344900 | ||||||||
| FaxNumber: | 5126344950 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 FORTUNE DR | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784053919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3612890889 | ||||||||
| FaxNumber: | 3612897516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 08/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | LEW | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5126344900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 126438 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001012304 | 05 | TX | MEDICAID | 005224 | 01 | TX | FACILITY ID NO. | OTHER |