Provider Demographics
NPI:1851734768
Name:PECAN TREE HOLDINGS, LLC
Entity Type:Organization
Organization Name:PECAN TREE HOLDINGS, LLC
Other - Org Name:PLANTATION OAKS SENIOR LIVING RESIDENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ED
Authorized Official - Prefix:MRS
Authorized Official - First Name:META
Authorized Official - Middle Name:B
Authorized Official - Last Name:MCCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-454-0801
Mailing Address - Street 1:201 NE 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:HIGH SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32643-9444
Mailing Address - Country:US
Mailing Address - Phone:386-454-0801
Mailing Address - Fax:386-454-4436
Practice Address - Street 1:201 NE 1ST AVE
Practice Address - Street 2:
Practice Address - City:HIGH SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32643-9444
Practice Address - Country:US
Practice Address - Phone:386-454-0801
Practice Address - Fax:386-454-4436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11967310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003409700Medicaid