Healthcare Provider Details

I. General information

NPI: 1023234978
Provider Name (Legal Business Name): ROCKDALE BLACKHAWK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 N MAIN ST
ROCKDALE TX
76567-2323
US

IV. Provider business mailing address

PO BOX 1010
ROCKDALE TX
76567-1010
US

V. Phone/Fax

Practice location:
  • Phone: 512-446-4555
  • Fax: 512-446-4533
Mailing address:
  • Phone: 512-446-4500
  • Fax: 512-446-0084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number000369
License Number StateTX

VIII. Authorized Official

Name: JEFF MADISON
Title or Position: CEO
Credential:
Phone: 512-446-4500