Healthcare Provider Details

I. General information

NPI: 1366626517
Provider Name (Legal Business Name): KERRVILLE MEDICAL SERVICES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 12/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 LA HACIENDA WAY LA HACIENDA TREATMENT CENTER
HUNT TX
78024
US

IV. Provider business mailing address

1365 SADDLEWOOD BLVD
KERRVILLE TX
78028-7231
US

V. Phone/Fax

Practice location:
  • Phone: 830-238-6123
  • Fax:
Mailing address:
  • Phone: 830-238-6123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberF6460
License Number StateTX

VIII. Authorized Official

Name: GEORGE DANIEL BOONE
Title or Position: PRESIDENT, KERRVILLE MEDICAL SERVIC
Credential: MD
Phone: 830-238-6123