Provider Demographics
NPI:1578639647
Name:DEPARTMENT OF STATE HEALTH SERVICES
Entity Type:Organization
Organization Name:DEPARTMENT OF STATE HEALTH SERVICES
Other - Org Name:TEXAS DSHS - HSR 1 LUBBOCK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY REGIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-744-3577
Mailing Address - Street 1:1100 W. 49TH ST.
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756
Mailing Address - Country:US
Mailing Address - Phone:806-458-7111
Mailing Address - Fax:
Practice Address - Street 1:6302 LOLA
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424
Practice Address - Country:US
Practice Address - Phone:806-744-3577
Practice Address - Fax:806-783-6475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QP0905X
TXH4610261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136480402Medicaid
TX138359805Medicaid
TX136368102Medicaid
TX135248602Medicaid
TX136129702Medicaid
TX136130504Medicaid
TX138359808Medicaid
TX133560602Medicaid
TX136480402Medicaid