Basic Information
Provider Information | |||||||||
NPI: | 1558770628 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PM MANAGEMENT KILLEEN I NC, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE ROSEWOOD RETIREMENT COMMUNITY ALF | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14841 DALLAS PKWY | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752547685 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2142527600 | ||||||||
FaxNumber: | 2142527704 | ||||||||
Practice Location | |||||||||
Address1: | 5701 E. CENTRAL TEXAS EXPRESSWAY | ||||||||
Address2: |   | ||||||||
City: | KILLEEN | ||||||||
State: | TX | ||||||||
PostalCode: | 76543 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2546805020 | ||||||||
FaxNumber: | 2546903238 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2014 | ||||||||
LastUpdateDate: | 03/16/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TEMPLETON | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2142527600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 136302 | TX | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | CBA-001020269 | 05 | TX |   | MEDICAID | 030300 | 01 |   | TDADS FACILITY ID | OTHER |