Basic Information
| Provider Information | |||||||||
| NPI: | 1891978847 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AHCS 3, LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COPPER CREEK PLAZA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 302 PEARLSTONE STREET | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033224208 | ||||||||
| FaxNumber: | 9033223874 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 PEARLSTONE STREET | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033224208 | ||||||||
| FaxNumber: | 9033223874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2007 | ||||||||
| LastUpdateDate: | 12/17/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8179197495 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMICUS HEALTH CARE SERVICES 2, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LNFA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 117842 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004916 | 05 | TX | MEDICAID |