Provider Demographics
NPI:1376969535
Name:DALLAS COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:DALLAS COUNTY HOSPITAL DISTRICT
Other - Org Name:SANDY LAKE REHABILITATION AND CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:CERISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-590-8006
Mailing Address - Street 1:1410 E SANDY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-3119
Mailing Address - Country:US
Mailing Address - Phone:972-304-4444
Mailing Address - Fax:
Practice Address - Street 1:1410 E SANDY LAKE RD
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-3119
Practice Address - Country:US
Practice Address - Phone:972-304-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001025870Medicaid
TX001025870Medicaid