Healthcare Provider Details

I. General information

NPI: 1841835022
Provider Name (Legal Business Name): SABINE VALLEY REGIONAL MHMR CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 WOODBINE PL
LONGVIEW TX
75601-2912
US

IV. Provider business mailing address

107 WOODBINE PL
LONGVIEW TX
75601-2912
US

V. Phone/Fax

Practice location:
  • Phone: 903-758-2471
  • Fax: 903-234-1639
Mailing address:
  • Phone: 903-234-4226
  • Fax: 903-234-1639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROSEMARY O VILLARREAL
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 903-234-4226