Basic Information
| Provider Information | |||||||||
| NPI: | 1912094111 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DALLAS COUNTY MENTAL HEALTH & MENTAL RETARDATION CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LANCASTER ADULT OP DCMHMR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3330 S LANCASTER RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752164531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143716639 | ||||||||
| FaxNumber: | 2143726218 | ||||||||
| Practice Location | |||||||||
| Address1: | 3330 S LANCASTER RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752164531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143716639 | ||||||||
| FaxNumber: | 2143726218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2006 | ||||||||
| LastUpdateDate: | 03/06/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EDERY | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIR | ||||||||
| AuthorizedOfficialTelephone: | 2147436180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0002X | 4093 | TX | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2099860 | 01 | PK | OTHER |