Basic Information
| Provider Information | |||||||||
| NPI: | 1366433518 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PECAN MANOR NURSING AND REHABILITATION LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 N ELM ST | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762014137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403874388 | ||||||||
| FaxNumber: | 9403802410 | ||||||||
| Practice Location | |||||||||
| Address1: | 413 MANSFIELD CARDINAL RD | ||||||||
| Address2: | |||||||||
| City: | KENNEDALE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760602805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175614495 | ||||||||
| FaxNumber: | 8175616033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 03/21/2012 | ||||||||
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| AuthorizedOfficialLastName: | RICH | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9403874388 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 115249 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001004226 | 05 | TX | MEDICAID | 153326702 | 01 | TX | TMHP (CROSS-OVER) | OTHER |