Healthcare Provider Details

I. General information

NPI: 1821214537
Provider Name (Legal Business Name): SABINE VALLEY REGIONAL MHMR CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 WOODBINE PL UNIT 775
LONGVIEW TX
75601-2912
US

IV. Provider business mailing address

107 WOODBINE PL UNIT 775
LONGVIEW TX
75601-2912
US

V. Phone/Fax

Practice location:
  • Phone: 903-918-5806
  • Fax: 903-295-5803
Mailing address:
  • Phone: 903-918-5806
  • Fax: 903-295-5803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROSEMARY O VILLARREAL
Title or Position: PROVIDER ENROLLMENT/CREDENTIALING
Credential:
Phone: 903-234-4226