Basic Information
Provider Information | |||||||||
NPI: | 1962694489 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STEEPLECHASE DIAGNOSTIC CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2569 | ||||||||
Address2: |   | ||||||||
City: | STAFFORD | ||||||||
State: | TX | ||||||||
PostalCode: | 774972569 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7136641330 | ||||||||
FaxNumber: | 7136643355 | ||||||||
Practice Location | |||||||||
Address1: | 10694 JONES RD | ||||||||
Address2: | SUITE 150-B | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770654278 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8667572687 | ||||||||
FaxNumber: | 8887572680 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2007 | ||||||||
LastUpdateDate: | 07/27/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BALAT | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGED CARE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7136641330 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
ID Information
ID | Type | State | Issuer | Description | 201906901 | 05 | TX |   | MEDICAID |