1124562053 NPI number — ROCKDALE BLACKHAWK, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124562053 NPI number — ROCKDALE BLACKHAWK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROCKDALE BLACKHAWK, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LITTLE RIVER HEALTHCARE SOUTHWEST ORTHOPEDIC GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124562053
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 CHISHOLM TRAIL
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
ROUND ROCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78681-5094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
815 HWY 71 W
Provider Second Line Business Practice Location Address:
SUITE 1150
Provider Business Practice Location Address City Name:
BASTROP
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78602-0319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-451-1969
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MADISON
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
512-481-7060

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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