Healthcare Provider Details

I. General information

NPI: 1003906876
Provider Name (Legal Business Name): HEART OF TEXAS REGION MENTAL HEALTH MENTAL RETARDATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 PARKSIDE DR
GROESBECK TX
76642-1125
US

IV. Provider business mailing address

110 S 12TH ST P O BOX 890
WACO TX
76701-1810
US

V. Phone/Fax

Practice location:
  • Phone: 254-729-8177
  • Fax: 254-729-8176
Mailing address:
  • Phone: 254-752-3451
  • Fax: 254-752-7421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateTX

VIII. Authorized Official

Name: MR. DANIEL THOMPSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 254-752-3451