Basic Information
Provider Information | |||||||||
NPI: | 1821612284 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KINDRED BH ACQUISITION 1, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WELLBRIDGE HEALTHCARE GREATER DALLAS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 680 S 4TH ST | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402022412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5025967220 | ||||||||
FaxNumber: | 5025964134 | ||||||||
Practice Location | |||||||||
Address1: | 4301 MAPLESHADE LN | ||||||||
Address2: |   | ||||||||
City: | PLANO | ||||||||
State: | TX | ||||||||
PostalCode: | 750930010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9725965445 | ||||||||
FaxNumber: | 9725962332 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2020 | ||||||||
LastUpdateDate: | 08/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DILLON | ||||||||
AuthorizedOfficialFirstName: | TERRANCE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AO / ASSISTANT SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 5025967220 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X |   |   | Y |   | Hospitals | Psychiatric Hospital |   |
No ID Information.