Provider Demographics
NPI:1568600195
Name:ALLEGIANCE HEALTH CENTER OF MIDLAND, LLC
Entity Type:Organization
Organization Name:ALLEGIANCE HEALTH CENTER OF MIDLAND, LLC
Other - Org Name:ALLEGIANCE HOSPITAL OF MIDLAND-PERMIAN BASIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROCK
Authorized Official - Middle Name:
Authorized Official - Last Name:BORDELON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-226-8202
Mailing Address - Street 1:504 TEXAS ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3526
Mailing Address - Country:US
Mailing Address - Phone:318-226-8202
Mailing Address - Fax:318-226-8205
Practice Address - Street 1:207 TRADEWINDS BLVD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79706-2807
Practice Address - Country:US
Practice Address - Phone:432-520-1401
Practice Address - Fax:432-529-1215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-04
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX273R00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX67S064Medicare Oscar/Certification
TX670064Medicare Oscar/Certification