Basic Information
| Provider Information | |||||||||
| NPI: | 1366814337 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PM MANAGEMENT -CORSICANA NC II, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HERITAGE OAKS RETIREMENT VILLAGE (ALF) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 N PEARL ST STE 1050 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752017495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142527600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3002 W 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | CORSICANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751102492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038725130 | ||||||||
| FaxNumber: | 9038725949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2015 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEAL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2142527600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 142141 | TX | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 142141 | 01 | TX | TDADS FACILITY LICENSE | OTHER |