Basic Information
Provider Information | |||||||||
NPI: | 1700955796 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THC - HOUSTON, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KINDRED HOSPITAL (BAY AREA) | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4801 E SAM HOUSTON PKWY S | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | TX | ||||||||
PostalCode: | 775053955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2819915463 | ||||||||
FaxNumber: | 2819911655 | ||||||||
Practice Location | |||||||||
Address1: | 4801 E SAM HOUSTON PKWY S | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | TX | ||||||||
PostalCode: | 77505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2819915463 | ||||||||
FaxNumber: | 2819911655 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/06/2006 | ||||||||
LastUpdateDate: | 05/02/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DILLON | ||||||||
AuthorizedOfficialFirstName: | TERRANCE | ||||||||
AuthorizedOfficialMiddleName: | K. | ||||||||
AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 5025967220 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | 000801 | TX | Y |   | Hospitals | Long Term Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 021017101 | 05 | TX |   | MEDICAID | HH0932 | 01 | TX | BLUE CROSS | OTHER |