Basic Information
| Provider Information | |||||||||
| NPI: | 1982894408 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROCKDALE BLACKHAWK, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LITTLE RIVER MEDICAL CLINIC - HEARNE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1010 | ||||||||
| Address2: | |||||||||
| City: | ROCKDALE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765671010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124464500 | ||||||||
| FaxNumber: | 5124462063 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 S MAGNOLIA ST | ||||||||
| Address2: | |||||||||
| City: | HEARNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778592565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9792800022 | ||||||||
| FaxNumber: | 9792800023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 02/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | DAVENPORT | ||||||||
| AuthorizedOfficialFirstName: | SHANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | INSURANCE CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 5124464500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.