Provider Demographics
NPI:1033436407
Name:PROVIDENCE HEALTH SERVICES OF WACO
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH SERVICES OF WACO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-325-1000
Mailing Address - Street 1:PO BOX 2589
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76702-2589
Mailing Address - Country:US
Mailing Address - Phone:254-751-4146
Mailing Address - Fax:254-751-4283
Practice Address - Street 1:301 LONDONDERRY DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7915
Practice Address - Country:US
Practice Address - Phone:254-751-4146
Practice Address - Fax:254-751-4283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-26
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000040283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45S042Medicare Oscar/Certification