Basic Information
| Provider Information | |||||||||
| NPI: | 1033126230 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPARTMENT OF STATE HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KERRVILLE STATE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4110 GUADALUPE ST | ||||||||
| Address2: | MC-2028 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787514223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122065011 | ||||||||
| FaxNumber: | 5122065302 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 THOMPSON DR | ||||||||
| Address2: | |||||||||
| City: | KERRVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780285154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308962211 | ||||||||
| FaxNumber: | 8308962373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 08/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | BALTIERRA | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | TEAM LEAD | ||||||||
| AuthorizedOfficialTelephone: | 5122065011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | TX | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 3336I0012X | TX | Y | Suppliers | Pharmacy | Institutional Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1273203-02 | 05 | TX | MEDICAID | HH3002 | 01 | TX | BCBS DRUG/ALCOHOL | OTHER | 1273203-03 | 05 | TX | MEDICAID | 4540185 | 01 | TX | PHARMACY NCPDP NUMBER | OTHER | 1081028-01 | 05 | TX | MEDICAID | HH4631 | 01 | TX | BCBS PSYCHIATRIC | OTHER | 1081028-02 | 05 | TX | MEDICAID |