Provider Demographics
NPI:1942428065
Name:PECAN VALLEY MHMR REGION
Entity Type:Organization
Organization Name:PECAN VALLEY MHMR REGION
Other - Org Name:TURKEY PEAK
Other - Org Type:Other Name
Authorized Official - Title/Position:MIS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:WHAITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-397-3147
Mailing Address - Street 1:650 W GREEN ST
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-3311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:908 BROWN CREST RD
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-5136
Practice Address - Country:US
Practice Address - Phone:817-447-8816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1014217320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
1014217OtherDADS CONTRACT