Basic Information
Provider Information | |||||||||
NPI: | 1225289499 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LUBBOCK HERITAGE HOSPITAL, LLC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GRACE SURGICAL HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2412 50TH ST | ||||||||
Address2: |   | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794122504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8067884000 | ||||||||
FaxNumber: | 8067884278 | ||||||||
Practice Location | |||||||||
Address1: | 7509 MARSHA SHARP FWY | ||||||||
Address2: |   | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794078202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8067254000 | ||||||||
FaxNumber: | 8067884278 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/07/2008 | ||||||||
LastUpdateDate: | 02/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PIPES | ||||||||
AuthorizedOfficialFirstName: | MELONIE | ||||||||
AuthorizedOfficialMiddleName: | ANN | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8067884085 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 13005 | TX | N |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QR0200X | R32837 | TX | N |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QR0206X | #M01038 | TX | N |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 282N00000X | 008366 | TX | N |   | Hospitals | General Acute Care Hospital |   | 282N00000X | 008730 | TX | N |   | Hospitals | General Acute Care Hospital |   | 291U00000X | 45D1057650 | TX | N |   | Laboratories | Clinical Medical Laboratory |   | 282N00000X | TX008366 | TX | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 2815144 | 05 | TX |   | MEDICAID | 281514401 | 05 | TX |   | MEDICAID | 281514402 | 05 | TX |   | MEDICAID |