1629064928 NPI number — SOUTHLAKE SPECIALTY HOSPITAL, LLC

Table of content: (NPI 1629064928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629064928 NPI number — SOUTHLAKE SPECIALTY HOSPITAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHLAKE SPECIALTY HOSPITAL, 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:
1629064928
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 735801
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75373-5801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-419-6704
Provider Business Mailing Address Fax Number:
972-419-8118

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1545 SOUTHLAKE BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHLAKE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76092-6422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-748-8784
Provider Business Practice Location Address Fax Number:
817-748-8787
Provider Enumeration Date:
09/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BERNARD
Authorized Official First Name:
TRACI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
817-748-8784

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  008128 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1714610-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: HH1061 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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