Basic Information
| Provider Information | |||||||||
| NPI: | 1154978476 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEER OAKS MID-WEST LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7272 WURZBACH RD STE 601 | ||||||||
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| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782404803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106153483 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2545 24TH ST | ||||||||
| Address2: | |||||||||
| City: | ROCK ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612015305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883656271 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2019 | ||||||||
| LastUpdateDate: | 08/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | BOSKIND | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2106153483 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.