Provider Demographics
NPI:1710989595
Name:PROVIDER HEALTHCARE SERVICES OF CONCHO LP
Entity Type:Organization
Organization Name:PROVIDER HEALTHCARE SERVICES OF CONCHO LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:IRVIN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:STRECKERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-869-5531
Mailing Address - Street 1:PO BOX 838
Mailing Address - Street 2:613 EAKER ST
Mailing Address - City:EDEN
Mailing Address - State:TX
Mailing Address - Zip Code:76837-0838
Mailing Address - Country:US
Mailing Address - Phone:325-869-5531
Mailing Address - Fax:325-869-5152
Practice Address - Street 1:613 EAKER ST
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:TX
Practice Address - Zip Code:76837
Practice Address - Country:US
Practice Address - Phone:325-869-5531
Practice Address - Fax:325-869-5152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113535314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX455737Medicare ID - Type UnspecifiedPROVIDER #