Basic Information
| Provider Information | |||||||||
| NPI: | 1053530980 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DALLAS COUNTY MHMR | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DALLAS METROCARE SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1380 RIVER BEND DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752474914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2147436159 | ||||||||
| FaxNumber: | 2146896482 | ||||||||
| Practice Location | |||||||||
| Address1: | 8014 INWOOD RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752093336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2147436159 | ||||||||
| FaxNumber: | 2146896482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | ROLANDA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2147436159 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 375605 | 01 | TX | ICFMR CONTRACT NUMBER | OTHER |