Basic Information
| Provider Information | |||||||||
| NPI: | 1366880627 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MESA SPRINGS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MESA SPRINGS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 S 5TH ST | ||||||||
| Address2: | SUITE 3850 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024008496 | ||||||||
| FaxNumber: | 5025834446 | ||||||||
| Practice Location | |||||||||
| Address1: | 5560 MESA SPRINGS DRIVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172924600 | ||||||||
| FaxNumber: | 8172924604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2013 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | WALL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 5024965959 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 339487601 | 05 | TX | MEDICAID |