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General NPI Number Information
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NPI Number | 1629064928
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Entity Type | Organization
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Legal Business Name | SOUTHLAKE SPECIALTY HOSPITAL, LLC
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Dates
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Enumeration Date | 09/22/2005
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Last Update Date | 02/18/2025
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Provider Practice Location Address
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Address Line | 1545 SOUTHLAKE BLVD.
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6422
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Country | US
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Telephone | 817-748-8784
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Fax | 817-748-8787
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Provider Business Mailing Address
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Address Line | PO BOX 735801
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City | DALLAS
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State | TX
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Zip | 75373-5801
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Country | US
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Telephone | 972-419-6704
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Fax | 972-419-8118
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. TRACI BERNARD
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Credential |
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Telephone | 817-748-8784
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 282N00000X
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Taxonomy Name | General Acute Care Hospital
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License Number | 008128
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License Number State | TX
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