Provider Demographics
NPI:1659371565
Name:MRC PINECREST
Entity Type:Organization
Organization Name:MRC PINECREST
Other - Org Name:PINCREST RETIREMENT COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEVON
Authorized Official - Middle Name:
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-210-0123
Mailing Address - Street 1:1302 TOM TEMPLE DR
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-5550
Mailing Address - Country:US
Mailing Address - Phone:936-634-1054
Mailing Address - Fax:936-634-1056
Practice Address - Street 1:1302 TOME TEMPLE DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-5550
Practice Address - Country:US
Practice Address - Phone:936-634-1054
Practice Address - Fax:936-634-1054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116427314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX676124Medicare ID - Type UnspecifiedMEDICARE PROVIDER #