Basic Information
| Provider Information | |||||||||
| NPI: | 1629102983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEART OF TEXAS MENTAL HEALTH MENTAL RETARDATION CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 890 | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767030890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547523451 | ||||||||
| FaxNumber: | 2547563133 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 S 12TH ST | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767011810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547523451 | ||||||||
| FaxNumber: | 2547563133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2547523451 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 084859002 | 05 | TX | MEDICAID |