Provider Demographics
NPI:1891786638
Name:PECAN RIDGE LIVING CENTER LTD
Entity Type:Organization
Organization Name:PECAN RIDGE LIVING CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-340-7155
Mailing Address - Street 1:845 PROTON RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4203
Mailing Address - Country:US
Mailing Address - Phone:210-340-7155
Mailing Address - Fax:210-340-4832
Practice Address - Street 1:1916 SELEY AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76704-2057
Practice Address - Country:US
Practice Address - Phone:254-799-6291
Practice Address - Fax:254-799-5340
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SURREY HOLDINGS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-01
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX003799310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001012117Medicaid