Basic Information
| Provider Information | |||||||||
| NPI: | 1184730988 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH AND HUMAN SERVICES COMMISSION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTH TEXAS STATE HOSPITAL (VERNON CAMPUS) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4110 GUADALUPE ST | ||||||||
| Address2: | HOSPITAL REVENUE MGMT. - MC2028 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787514223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122065011 | ||||||||
| FaxNumber: | 5122065302 | ||||||||
| Practice Location | |||||||||
| Address1: | 4730 COLLEGE DR | ||||||||
| Address2: | |||||||||
| City: | VERNON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763844009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405524055 | ||||||||
| FaxNumber: | 9405532523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 07/31/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM SUPERVISOR VI | ||||||||
| AuthorizedOfficialTelephone: | 5124383124 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | TX | N | Suppliers | Pharmacy | Institutional Pharmacy | 3336L0003X | TX | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1081036-02 | 05 | TX | MEDICAID | 1301640-07 | 05 | TX | MEDICAID | HH3011 | 01 | TX | BCBS ADOLESCENT | OTHER | 1081036-01 | 05 | TX | MEDICAID | HH4008 | 01 | TX | BCBS FORENSIC | OTHER | 0211963-01 | 05 | TX | MEDICAID | 4539219 | 01 | TX | PHARMACY NCPDP NUMBER | OTHER |