Provider Demographics
NPI:1982894408
Name:ROCKDALE BLACKHAWK, LLC
Entity type:Organization
Organization Name:ROCKDALE BLACKHAWK, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-446-4500
Mailing Address - Street 1:PO BOX 1010
Mailing Address - Street 2:
Mailing Address - City:ROCKDALE
Mailing Address - State:TX
Mailing Address - Zip Code:76567-1010
Mailing Address - Country:US
Mailing Address - Phone:512-446-4500
Mailing Address - Fax:512-446-2063
Practice Address - Street 1:104 S MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:HEARNE
Practice Address - State:TX
Practice Address - Zip Code:77859-2565
Practice Address - Country:US
Practice Address - Phone:979-280-0022
Practice Address - Fax:979-280-0023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care