Basic Information
Provider Information | |||||||||
NPI: | 1215974688 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IRON MOUNTAIN MEDICAL CENTER LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RHPA DBA IRON MOUNTAIN MEDICAL CENTER LLC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 106 N GRACE ST | ||||||||
Address2: |   | ||||||||
City: | CROCKETT | ||||||||
State: | TX | ||||||||
PostalCode: | 758351722 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9363489141 | ||||||||
FaxNumber: | 9363489143 | ||||||||
Practice Location | |||||||||
Address1: | 106 N GRACE ST | ||||||||
Address2: |   | ||||||||
City: | CROCKETT | ||||||||
State: | TX | ||||||||
PostalCode: | 758351722 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9365447202 | ||||||||
FaxNumber: | 9365462029 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HORNE | ||||||||
AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
AuthorizedOfficialMiddleName: | RAYE | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9363489141 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RN | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0037RB | 01 | TX | BCBS | OTHER | 138350710 | 01 | TX | PCP | OTHER | 0051BV | 01 | TX | BCBS | OTHER | 092386401 | 05 | TX |   | MEDICAID | 092386403 | 05 | TX |   | MEDICAID |