Basic Information
Provider Information | |||||||||
NPI: | 1427353770 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROCKDALE BLACKHAWK LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LITTLE RIVER HEALTHCARE BASTROP IMAGING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3101 HIGHWAY 71 E | ||||||||
Address2: | SUITE 108 | ||||||||
City: | BASTROP | ||||||||
State: | TX | ||||||||
PostalCode: | 786025156 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5123320222 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3101 HIGHWAY 71 E | ||||||||
Address2: | SUITE 108 | ||||||||
City: | BASTROP | ||||||||
State: | TX | ||||||||
PostalCode: | 786025156 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5123320222 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/18/2011 | ||||||||
LastUpdateDate: | 05/14/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MADISON | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 5124464500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.