Healthcare Provider Details

I. General information

NPI: 1528269123
Provider Name (Legal Business Name): BLUEBONNET TRAILS MHMR CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 N GEORGETOWN ST
ROUND ROCK TX
78664-3289
US

IV. Provider business mailing address

1009 N GEORGETOWN ST
ROUND ROCK TX
78664-3289
US

V. Phone/Fax

Practice location:
  • Phone: 512-255-1720
  • Fax: 512-244-8371
Mailing address:
  • Phone: 512-255-1720
  • Fax: 512-244-8371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License NumberNO LICENSE
License Number StateTX

VIII. Authorized Official

Name: MS. NORALISA WILLIAMS
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 512-244-8374