Provider Demographics
NPI:1629163860
Name:PECAN GROVE HEALTH CARE LP
Entity Type:Organization
Organization Name:PECAN GROVE HEALTH CARE LP
Other - Org Name:KATELAND SQUARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SCOTCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-597-5445
Mailing Address - Street 1:1106 GOLFVIEW DR
Mailing Address - Street 2:P.O. BOX 1189
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469-5120
Mailing Address - Country:US
Mailing Address - Phone:281-344-9191
Mailing Address - Fax:830-597-5361
Practice Address - Street 1:1106 GOLFVIEW DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-5120
Practice Address - Country:US
Practice Address - Phone:281-344-9191
Practice Address - Fax:830-597-5361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5273314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX675901Medicare ID - Type Unspecified