Basic Information
| Provider Information | |||||||||
| NPI: | 1164890141 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SDS PSYCHIATRIC SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2922 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756062922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033310506 | ||||||||
| FaxNumber: | 9033310462 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 CLINIC DR | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756055172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032123105 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2015 | ||||||||
| LastUpdateDate: | 09/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | SHAH | ||||||||
| AuthorizedOfficialFirstName: | SHAUNA | ||||||||
| AuthorizedOfficialMiddleName: | DESAI | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 9033310506 | ||||||||
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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 | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.