Basic Information
| Provider Information | |||||||||
| NPI: | 1104910413 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DALLAS COUNTY MENTAL HEALTH & MENTAL RETARDATION CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WESTMORELAND ADULT OC DCMHMR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1350 N WESTMORELAND RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752111654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143300036 | ||||||||
| FaxNumber: | 2143332762 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 N WESTMORELAND RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752111654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143300036 | ||||||||
| FaxNumber: | 2143332762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 03/06/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EDERY | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2147436180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336M0002X | N | Suppliers | Pharmacy | Mail Order Pharmacy | 333600000X | N | Suppliers | Pharmacy | 3336C0002X | 969 | TX | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2095119 | 01 | PK | OTHER | 350135 | 05 | TX | MEDICAID |