Provider Demographics
NPI:1588646186
Name:INTREPID OF SOUTHEAST TEXAS INC
Entity Type:Organization
Organization Name:INTREPID OF SOUTHEAST TEXAS INC
Other - Org Name:INTREPID USA HEALTHCARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KUNYSZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:214-445-3750
Mailing Address - Street 1:14841 DALLAS PKWY STE 625
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-7641
Mailing Address - Country:US
Mailing Address - Phone:214-445-3750
Mailing Address - Fax:214-445-3902
Practice Address - Street 1:1480 CORNERSTONE CT
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-3896
Practice Address - Country:US
Practice Address - Phone:409-722-0515
Practice Address - Fax:409-722-0633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX002511251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX095167503Medicaid
TX095167503Medicaid