Provider Demographics
NPI:1679184733
Name:PECAN BAYOU HEALTHCARE LLC
Entity Type:Organization
Organization Name:PECAN BAYOU HEALTHCARE LLC
Other - Org Name:CMS-KINDER HEARTS HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-401-1369
Mailing Address - Street 1:1102 EARLY BLVD
Mailing Address - Street 2:
Mailing Address - City:EARLY
Mailing Address - State:TX
Mailing Address - Zip Code:76802-2261
Mailing Address - Country:US
Mailing Address - Phone:325-646-4900
Mailing Address - Fax:
Practice Address - Street 1:1102 EARLY BLVD
Practice Address - Street 2:
Practice Address - City:EARLY
Practice Address - State:TX
Practice Address - Zip Code:76802-2261
Practice Address - Country:US
Practice Address - Phone:325-646-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-12
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health