Provider Demographics
NPI:1972585552
Name:INTREPID OF SAN ANTONIO INC
Entity type:Organization
Organization Name:INTREPID OF SAN ANTONIO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF COMPLIANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:CECELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-445-3750
Mailing Address - Street 1:4055 VALLEY VIEW LN
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-5074
Mailing Address - Country:US
Mailing Address - Phone:214-445-3750
Mailing Address - Fax:214-445-3902
Practice Address - Street 1:8632 FREDERICKSBURG
Practice Address - Street 2:STE 209
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240
Practice Address - Country:US
Practice Address - Phone:210-408-0070
Practice Address - Fax:210-408-0071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX002732251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX024610001Medicaid
TX024610001Medicaid