1518536309 NPI number — BLUEBONNET TRAILS COMMUNITY MHMR CENTER

Table of content: (NPI 1518536309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518536309 NPI number — BLUEBONNET TRAILS COMMUNITY MHMR CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUEBONNET TRAILS COMMUNITY MHMR 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:
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:
1518536309
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1009 N GEORGETOWN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROUND ROCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78664-3289
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-255-1720
Provider Business Mailing Address Fax Number:
512-244-8401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 W TRAVIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA GRANGE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78945-2522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-255-1720
Provider Business Practice Location Address Fax Number:
512-244-8401
Provider Enumeration Date:
06/24/2021

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARDSON
Authorized Official First Name:
ANDREA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
512-244-8305

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: 1268443-05 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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