Healthcare Provider Details

I. General information

NPI: 1093956831
Provider Name (Legal Business Name): BLACK CASINO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2009
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 WASHINGTON ST SUITE B
LAREDO TX
78040
US

IV. Provider business mailing address

302 WASHINGTON SUITE B
LAREDO TX
78040
US

V. Phone/Fax

Practice location:
  • Phone: 956-726-1812
  • Fax: 956-726-1270
Mailing address:
  • Phone: 956-726-1812
  • Fax: 956-726-1270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number149376
License Number StateTX

VIII. Authorized Official

Name: MRS. TERESA PADILLA
Title or Position: SECRETARY
Credential:
Phone: 956-726-1812