Healthcare Provider Details

I. General information

NPI: 1295765469
Provider Name (Legal Business Name): DEPARTMENT OF STATE HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W 49TH ST MAIL CODE 1917, ROOM G-109
AUSTIN TX
78756-3101
US

IV. Provider business mailing address

1100 W 49TH ST MAIL CODE 1917, ROOM G-109
AUSTIN TX
78756-3101
US

V. Phone/Fax

Practice location:
  • Phone: 512-458-7111
  • Fax: 512-458-7588
Mailing address:
  • Phone: 512-458-7111
  • Fax: 512-458-7588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. BARBARA SUZANNE KELLY-KING
Title or Position: BILLING BRANCH MANAGER
Credential:
Phone: 512-458-7111