Provider Demographics
NPI:1225289499
Name:LUBBOCK HERITAGE HOSPITAL, LLC.
Entity Type:Organization
Organization Name:LUBBOCK HERITAGE HOSPITAL, LLC.
Other - Org Name:GRACE SURGICAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY OF ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 676200
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-6200
Mailing Address - Country:US
Mailing Address - Phone:806-725-4000
Mailing Address - Fax:806-725-4001
Practice Address - Street 1:7509 MARSHA SHARP FWY
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-8202
Practice Address - Country:US
Practice Address - Phone:806-725-4000
Practice Address - Fax:806-788-4278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13005261QA1903X
TXR32837261QR0200X
TX#M01038261QR0206X
TX008366282N00000X
TX008730282N00000X
TXTX008366282N00000X
TX45D1057650291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX281514402Medicaid
TX2815144Medicaid
TX281514401Medicaid
TX281514402Medicaid