1285911123 NPI number — ROCKDALE BLACKHAWK, LLC

Table of content: (NPI 1285911123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285911123 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:
Provider Other Organization Name Type Code:
6
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:
1285911123
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1010
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKDALE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-446-4500
Provider Business Mailing Address Fax Number:
512-446-0084

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 BRAZOS
Provider Second Line Business Practice Location Address:
SUITE A, B AND C
Provider Business Practice Location Address City Name:
ROCKDALE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-446-4500
Provider Business Practice Location Address Fax Number:
512-446-0084
Provider Enumeration Date:
11/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MADISON
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
512-446-4500

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 321720001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com