Provider Demographics
NPI:1740474261
Name:ENCHANTED PINES, INC.
Entity type:Organization
Organization Name:ENCHANTED PINES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-545-6889
Mailing Address - Street 1:1154 E LOOP 304
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-1810
Mailing Address - Country:US
Mailing Address - Phone:936-544-5065
Mailing Address - Fax:936-546-5674
Practice Address - Street 1:1154 E LOOP 304
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:TX
Practice Address - Zip Code:75835-1810
Practice Address - Country:US
Practice Address - Phone:936-544-5065
Practice Address - Fax:936-546-2694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000617310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001004039Medicaid
TX001004040Medicaid