Provider Demographics
NPI:1083622781
Name:KERRVILLE CANCER CENTER LTD
Entity Type:Organization
Organization Name:KERRVILLE CANCER CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RIOS
Authorized Official - Suffix:
Authorized Official - Credentials:CCS-P
Authorized Official - Phone:830-257-2191
Mailing Address - Street 1:218 SIDNEY BAKER ST
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-5367
Mailing Address - Country:US
Mailing Address - Phone:830-257-2070
Mailing Address - Fax:830-257-2079
Practice Address - Street 1:218 SIDNEY BAKER ST
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5367
Practice Address - Country:US
Practice Address - Phone:830-257-2070
Practice Address - Fax:830-257-2079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR17560261QX0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0143426801Medicaid
TX0153DCOtherBC/BS
TX0143426801Medicaid