Provider Demographics
NPI: | 1265648927 |
---|---|
Name: | ROCKDALE BLACKHAWK LLC |
Entity type: | Organization |
Organization Name: | ROCKDALE BLACKHAWK LLC |
Other - Org Name: | <UNAVAIL> |
Other - Org Type: | |
Authorized Official - Title/Position: | SUPERVISOR, INSURANCE CREDENTIALING |
Authorized Official - Prefix: | |
Authorized Official - First Name: | SHANA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | DAVENPORT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 512-446-4500 |
Mailing Address - Street 1: | PO BOX 1010 |
Mailing Address - Street 2: | |
Mailing Address - City: | ROCKDALE |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 76567-1010 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 512-446-4500 |
Mailing Address - Fax: | 512-446-2063 |
Practice Address - Street 1: | 1700 BRAZOS AVE |
Practice Address - Street 2: | |
Practice Address - City: | ROCKDALE |
Practice Address - State: | TX |
Practice Address - Zip Code: | 76567-2517 |
Practice Address - Country: | US |
Practice Address - Phone: | 512-445-4500 |
Practice Address - Fax: | 512-446-2063 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-05-16 |
Last Update Date: | 2008-02-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 000369 | 332B00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies |