Provider Demographics
NPI:1003096488
Name:SOUTHERN HEALTH CORP. OF HOUSTON, INC.
Entity Type:Organization
Organization Name:SOUTHERN HEALTH CORP. OF HOUSTON, INC.
Other - Org Name:TRACE REGIONAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-456-3700
Mailing Address - Street 1:PO BOX 626
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851-0626
Mailing Address - Country:US
Mailing Address - Phone:662-456-1163
Mailing Address - Fax:662-456-1159
Practice Address - Street 1:1002 E MADISON ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-2417
Practice Address - Country:US
Practice Address - Phone:662-456-1163
Practice Address - Fax:662-456-1159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12-296261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center