Basic Information
Provider Information | |||||||||
NPI: | 1639422504 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EMERUS BHS SA THOUSAND OAKS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BAPTIST NEIGHBORHOOD HOSPITAL SCHERTZ | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8686 NEW TRAILS DR | ||||||||
Address2: | SUITE 100 | ||||||||
City: | THE WOODLANDS | ||||||||
State: | TX | ||||||||
PostalCode: | 773811176 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7136371144 | ||||||||
FaxNumber: | 2812923585 | ||||||||
Practice Location | |||||||||
Address1: | 16977 I-35 N | ||||||||
Address2: |   | ||||||||
City: | SCHERTZ | ||||||||
State: | TX | ||||||||
PostalCode: | 78154 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2105728400 | ||||||||
FaxNumber: | 2106510951 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2012 | ||||||||
LastUpdateDate: | 02/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUCK | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9362035996 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 309798201 | 05 | TX |   | MEDICAID |