Provider Demographics
NPI:1184185654
Name:PMG OPCO-WASHINGTON LLC
Entity Type:Organization
Organization Name:PMG OPCO-WASHINGTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOULWARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-428-0900
Mailing Address - Street 1:7605 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-5162
Mailing Address - Country:US
Mailing Address - Phone:318-219-2608
Mailing Address - Fax:318-861-7685
Practice Address - Street 1:7605 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-5162
Practice Address - Country:US
Practice Address - Phone:318-219-2608
Practice Address - Fax:318-861-7685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility