Provider Demographics
NPI:1861767832
Name:PELICAN ASSISTED LIVING LLC
Entity type:Organization
Organization Name:PELICAN ASSISTED LIVING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:409-962-4450
Mailing Address - Street 1:4500 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:GROVES
Mailing Address - State:TX
Mailing Address - Zip Code:77619-4712
Mailing Address - Country:US
Mailing Address - Phone:409-962-4450
Mailing Address - Fax:409-962-9253
Practice Address - Street 1:2501 S MAJOR DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-5018
Practice Address - Country:US
Practice Address - Phone:409-860-3500
Practice Address - Fax:409-962-9253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-09
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX32044376872OtherTEXAS COMPTROLLER OF PUBLIC ACCOUNTS TAXPAYER NUMBER
TX=========OtherEMPLOYER IDENTIFICATION NUMBER