Basic Information
| Provider Information | |||||||||
| NPI: | 1417255233 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DALLAS COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CANTON OAKS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 RIDGEBROOK RD | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211529390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107731000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1901 S TRADE DAYS BLVD | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035670444 | ||||||||
| FaxNumber: | 9035670445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2011 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CERISE | ||||||||
| AuthorizedOfficialFirstName: | FREDERICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2145908006 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001019566 | 05 | TX | MEDICAID |