Basic Information
| Provider Information | |||||||||
| NPI: | 1700193588 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DALLAS COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRENTWOOD PLACE FOUR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 HARRY HINES BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145908006 | ||||||||
| FaxNumber: | 2145908096 | ||||||||
| Practice Location | |||||||||
| Address1: | 3505 S BUCKNER BLVD | ||||||||
| Address2: | BUILDING 5 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752275534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143811815 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2010 | ||||||||
| LastUpdateDate: | 11/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | CERISE | ||||||||
| AuthorizedOfficialFirstName: | FREDERICK | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2145908006 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 | 001026677 | 05 | TX | MEDICAID |