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General NPI Number Information
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NPI Number | 1811382948
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Entity Type | Organization
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Legal Business Name | SACRED HEART PHC,LLC
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Dates
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Enumeration Date | 04/06/2015
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Last Update Date | 07/07/2015
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Provider Practice Location Address
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Address Line | 103 W GRAVIS ST
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City | SAN DIEGO
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State | TX
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Zip | 78384-2639
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Country | US
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Telephone | 361-279-8280
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Fax | 361-279-4128
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Provider Business Mailing Address
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Address Line | 103 W GRAVIS ST
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City | SAN DIEGO
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State | TX
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Zip | 78384-2639
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Country | US
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Telephone | 361-279-8280
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Fax | 361-279-4128
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | GLENDA RENEE GONZALEZ
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Credential | LVN
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Telephone | 361-834-3526
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3747P1801X
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Taxonomy Name | Personal Care Attendant
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License Number | 016703
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License Number State | TX
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