1568403574 NPI number — NORTHEAST TEXAS MENTAL HEALTH MENTAL RETARDATION CENTER

Table of content: (NPI 1568403574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568403574 NPI number — NORTHEAST TEXAS MENTAL HEALTH MENTAL RETARDATION CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST TEXAS MENTAL HEALTH MENTAL RETARDATION CENTER
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:
Provider Other Organization Name Type Code:
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:
1568403574
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5637
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75505-5637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-831-7585
Provider Business Mailing Address Fax Number:
903-831-4823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 C OAKLAWN CENTER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75501-4159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-831-7585
Provider Business Practice Location Address Fax Number:
903-831-4823
Provider Enumeration Date:
06/09/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FREEMAN
Authorized Official First Name:
BETSY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATIVE & FINANCE DIRECTOR
Authorized Official Telephone Number:
903-831-3646

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00PM39 . This is a "BLUECROSSBLUESHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".