Basic Information
| Provider Information | |||||||||
| NPI: | 1750575965 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HONDO HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MEDINA COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 AVENUE E | ||||||||
| Address2: | |||||||||
| City: | HONDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788613534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8304267700 | ||||||||
| FaxNumber: | 8304267975 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 AVENUE E | ||||||||
| Address2: | |||||||||
| City: | HONDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788613534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8304267700 | ||||||||
| FaxNumber: | 8304267975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2007 | ||||||||
| LastUpdateDate: | 04/01/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOMINGUEZ | ||||||||
| AuthorizedOfficialFirstName: | DELIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAID COLLECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8304267874 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 082496301 | 05 | TX | MEDICAID |