Provider Demographics
NPI:1063858298
Name:CROCKETT SENIOR CARE, LLC
Entity Type:Organization
Organization Name:CROCKETT SENIOR CARE, LLC
Other - Org Name:PITTSBURG NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-399-6788
Mailing Address - Street 1:200 W STATE HIGHWAY 6
Mailing Address - Street 2:SUITE 612
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-7923
Mailing Address - Country:US
Mailing Address - Phone:254-399-6788
Mailing Address - Fax:254-399-6766
Practice Address - Street 1:200 W STATE HWY 6
Practice Address - Street 2:SUITE 612
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712
Practice Address - Country:US
Practice Address - Phone:254-399-6788
Practice Address - Fax:254-399-6766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001021232Medicaid
TX675037Medicare Oscar/Certification