Provider Demographics
NPI:1972663813
Name:PM MANAGEMENT-SAN ANGELO NC I LLC
Entity Type:Organization
Organization Name:PM MANAGEMENT-SAN ANGELO NC I LLC
Other - Org Name:TRISUN CARE CENTER-MEADOW CREEK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEW
Authorized Official - Middle Name:N
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:512-634-4900
Mailing Address - Street 1:1703 W. FIFTH ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703
Mailing Address - Country:US
Mailing Address - Phone:512-634-4900
Mailing Address - Fax:512-634-4950
Practice Address - Street 1:4343 OAK GROVE BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-4550
Practice Address - Country:US
Practice Address - Phone:325-949-2559
Practice Address - Fax:325-949-3598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX128894314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000170OtherFACILITY ID NO.
TX001018223Medicaid
TX001018223Medicaid