Provider Demographics
NPI:1508025396
Name:PHCS IV, INC.
Entity Type:Organization
Organization Name:PHCS IV, INC.
Other - Org Name:PREMIER HEALTHCARE SERVICES-LAKESIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-526-0443
Mailing Address - Street 1:1021 E SOUTHEAST LOOP 323 STE 110B
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-9656
Mailing Address - Country:US
Mailing Address - Phone:903-526-0443
Mailing Address - Fax:903-526-3482
Practice Address - Street 1:1021 E SOUTHEAST LOOP 323 STE 110B
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9656
Practice Address - Country:US
Practice Address - Phone:903-526-0443
Practice Address - Fax:469-374-5420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health