Basic Information
| Provider Information | |||||||||
| NPI: | 1043280951 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEXAS LAUREL RIDGE HOSPITAL LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LAUREL RIDGE TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 17720 CORPORATE WOODS DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782593500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104919400 | ||||||||
| FaxNumber: | 2104913517 | ||||||||
| Practice Location | |||||||||
| Address1: | 17720 CORPORATE WOODS DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782593500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104919400 | ||||||||
| FaxNumber: | 2104913517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 10/28/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FILTON | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SRVP CFO | ||||||||
| AuthorizedOfficialTelephone: | 6107683300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | 827024 | TX | N | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | 283Q00000X | 000723 | TX | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 149461125 | 05 | AK | MEDICAID | 06704836 | 05 | MS | MEDICAID | HH6534 | 01 | TX | BC PARTIAL PIN | OTHER | 2000114300A | 05 | OK | MEDICAID | 0413423 | 05 | MO | MEDICAID | 1707414 | 05 | LA | MEDICAID | 6388590 | 05 | NV | MEDICAID | HH3825 | 01 | TX | BC CD PIN | OTHER | 783771 | 05 | AZ | MEDICAID | HH0825 | 01 | TX | BC ACUTE PIN | OTHER | 119465 | 01 | PA | CBH PIN | OTHER | 51754339 | 05 | NM | MEDICAID | 0012278 | 05 | IA | MEDICAID | 21240902 | 05 | TX | MEDICAID | HS795PI | 05 | AK | MEDICAID | 001951370001 | 05 | PA | MEDICAID | HH6623 | 01 | TX | BC RTC PIN | OTHER |