Basic Information
| Provider Information | |||||||||
| NPI: | 1407252448 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCCULLOCH COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PECAN VALLEY HEALTHCARE RESIDENCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1405 W STOREY ST | ||||||||
| Address2: | |||||||||
| City: | SAN SABA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 768776422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3253725112 | ||||||||
| FaxNumber: | 3253725114 | ||||||||
| Practice Location | |||||||||
| Address1: | 1405 W STOREY ST | ||||||||
| Address2: | |||||||||
| City: | SAN SABA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 768776422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3253725112 | ||||||||
| FaxNumber: | 3253725114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2014 | ||||||||
| LastUpdateDate: | 12/31/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3255972901 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004476 | 05 | TX | MEDICAID |