Provider Demographics
NPI:1053316331
Name:PINE RIDGE HEALTH CARE L L P
Entity Type:Organization
Organization Name:PINE RIDGE HEALTH CARE L L P
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:MAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:PANOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-444-2516
Mailing Address - Street 1:7150 GANTT ACCESS
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-5638
Mailing Address - Country:US
Mailing Address - Phone:817-444-2516
Mailing Address - Fax:
Practice Address - Street 1:1620 HIGHWAY 59 LOOP N
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-9988
Practice Address - Country:US
Practice Address - Phone:936-327-5415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113069314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001001771Medicaid
TX001001771Medicaid
TX676000Medicare Oscar/Certification