Provider Demographics
NPI:1477509883
Name:SOUTHWEST SIDS RESEARCH INSTITUTE, INC.
Entity Type:Organization
Organization Name:SOUTHWEST SIDS RESEARCH INSTITUTE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HENSLEE
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:979-297-2101
Mailing Address - Street 1:230 PARKING WAY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5227
Mailing Address - Country:US
Mailing Address - Phone:979-297-2101
Mailing Address - Fax:979-297-6682
Practice Address - Street 1:230 PARKING WAY ST
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5227
Practice Address - Country:US
Practice Address - Phone:979-297-2101
Practice Address - Fax:979-297-6682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160588303Medicaid