Basic Information
| Provider Information | |||||||||
| NPI: | 1477877603 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CROCKETT SENIOR CARE LLC | ||||||||
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| OtherOrganizationName: | COMMUNITY CARE CENTER OF CROCKETT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 W HIGHWAY 6 | ||||||||
| Address2: | SUITE 509 | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767127923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543996788 | ||||||||
| FaxNumber: | 2543996766 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 E LOOP 304 | ||||||||
| Address2: | |||||||||
| City: | CROCKETT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 758351810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365442051 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2010 | ||||||||
| LastUpdateDate: | 03/17/2010 | ||||||||
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| AuthorizedOfficialLastName: | NEAL | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2543996788 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.