MEDICARE: ROCKDALE BLACKHAWK LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1407072358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCKDALE BLACKHAWK LLC

Provider Business Mailing Address
First Line	:	PO BOX 1010
Second Line	:
City	:	ROCKDALE
State	:	TX
Zip	:	76567-1010
Country	:	US
Telephone Number	:	512-446-4500
Fax Number	:	512-446-0084

Provider Business Practice Location Address
First Line	:	708 N CROCKETT AVE
Second Line	:
City	:	CAMERON
State	:	TX
Zip	:	76520-2551
Country	:	US
Telephone Number	:	254-697-6554
Fax Number	:	254-697-6643

Authorized Official
Title or Position	:	CEO
Name	:	JEFFREY P MADISON
Credential	:
Telephone Number	:	512-446-4500

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	02/11/2015

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