Basic Information
| Provider Information | |||||||||
| NPI: | 1447336060 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PM MANAGEMENT-PORTLAND AL, LLC | ||||||||
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| OtherOrganizationName: | TRISUN ASSISTED LIVING-PAVILION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 N PEARL ST | ||||||||
| Address2: | SUITE 1100 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752012822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142527600 | ||||||||
| FaxNumber: | 2142527704 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 CEDAR DR | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783742900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617774250 | ||||||||
| FaxNumber: | 3617772892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 05/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | KERR | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2142527600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 118187 | TX | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 010345 | 01 | TX | FACILITY ID NO. | OTHER |