Basic Information
| Provider Information | |||||||||
| NPI: | 1639310634 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LTHM GROVES - OPERATIONS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RENAISSANCE HOSPITAL - GROVES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5500 39TH ST | ||||||||
| Address2: | |||||||||
| City: | GROVES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776192905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4099625733 | ||||||||
| FaxNumber: | 4099635202 | ||||||||
| Practice Location | |||||||||
| Address1: | 5500 39TH ST | ||||||||
| Address2: | |||||||||
| City: | GROVES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776192905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4099625733 | ||||||||
| FaxNumber: | 4099635202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2009 | ||||||||
| LastUpdateDate: | 10/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | SOILEAU | ||||||||
| AuthorizedOfficialFirstName: | DAMIAN | ||||||||
| AuthorizedOfficialMiddleName: | KIRK | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8328661840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 100006 | TX | N | Hospital Units | Psychiatric Unit | 282N00000X | 100006 | TX | Y | Hospitals | General Acute Care Hospital |
No ID Information.