Basic Information
| Provider Information | |||||||||
| NPI: | 1144679028 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROCKDALE BLACKHHAWK, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | LITTLE RIVER HEALTHCARE - CORNERSTONE MEDICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1010 | ||||||||
| Address2: | |||||||||
| City: | ROCKDALE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765671010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124464500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6600 FISH POND RD | ||||||||
| Address2: | SUITE 202A | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767102581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542657300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2016 | ||||||||
| LastUpdateDate: | 06/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | BORGFELD | ||||||||
| AuthorizedOfficialFirstName: | PEGGY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5124464500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.