Basic Information
| Provider Information | |||||||||
| NPI: | 1316944390 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UVALDE COUNTY HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | UVALDE HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 124 ROYAL LN | ||||||||
| Address2: | |||||||||
| City: | UVALDE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788014838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302786251 | ||||||||
| FaxNumber: | 8302783756 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 ROYAL LN | ||||||||
| Address2: | |||||||||
| City: | UVALDE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788014838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302786691 | ||||||||
| FaxNumber: | 9302787533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 11/17/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUCKNER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8302786251 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 000063 | TX | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 024112701 | 05 | TX | MEDICAID | HH010C | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |