Basic Information
| Provider Information | |||||||||
| NPI: | 1811489974 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCKDALE BLACKHAWK, LLC | ||||||||
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| OtherOrganizationName: | LITTLE RIVER HEALTHCARE - TEMPLE SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 BRAZOS AVENUE | ||||||||
| Address2: | |||||||||
| City: | ROCKDALE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124464500 | ||||||||
| FaxNumber: | 5124460084 | ||||||||
| Practice Location | |||||||||
| Address1: | 1909 SW HK DODGEN LOOP | ||||||||
| Address2: | |||||||||
| City: | TEMPLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542982530 | ||||||||
| FaxNumber: | 2547770207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2018 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | BORGFELD | ||||||||
| AuthorizedOfficialFirstName: | PEGGY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5124464502 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 130224 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.