Provider Demographics
NPI:1457653099
Name:PM MANAGEMENT - GOLDEN TRIANGLE NC III LLC
Entity Type:Organization
Organization Name:PM MANAGEMENT - GOLDEN TRIANGLE NC III LLC
Other - Org Name:CYPRESS GLEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-252-7600
Mailing Address - Street 1:600 N PEARL ST STE 1050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-7495
Mailing Address - Country:US
Mailing Address - Phone:214-252-7600
Mailing Address - Fax:214-252-7704
Practice Address - Street 1:7200 9TH AVE
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-6405
Practice Address - Country:US
Practice Address - Phone:409-729-8701
Practice Address - Fax:409-729-5722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX131482314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001019215Medicaid
TX050720OtherFACILITY ID
TX001019215Medicaid