=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629185566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEXAR COUNTY MHMR BOARD OF TRUSTEES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2006
-----------------------------------------------------
Last Update Date | 05/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8155 LONE SHADOW TRL
-----------------------------------------------------
City | CONVERSE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78109-2436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-659-5857
-----------------------------------------------------
Fax | 210-659-7460
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6800 PARK TEN BLVD STE 200S
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78213-4293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-261-1000
-----------------------------------------------------
Fax | 210-261-1821
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SUPERVISOR
-----------------------------------------------------
Name | EUGENE GARCIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-261-1072
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 004276
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------