Basic Information
| Provider Information | |||||||||
| NPI: | 1114473329 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMERUS BHS SA THOUSAND OAKS LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BAPTIST NEIGHBORHOOD HOSPITAL SHAVANO PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8686 NEW TRAILS DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773811176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136371146 | ||||||||
| FaxNumber: | 2812985311 | ||||||||
| Practice Location | |||||||||
| Address1: | 4103 N LOOP 1604 W | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105728415 | ||||||||
| FaxNumber: | 7136371305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2016 | ||||||||
| LastUpdateDate: | 02/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUCK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9362035996 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 100116 | TX | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 309798201 | 05 | TX | MEDICAID |