Provider Demographics
NPI:1609007756
Name:ROCKDALE BLACKHAWK LLC
Entity Type:Organization
Organization Name:ROCKDALE BLACKHAWK LLC
Other - Org Name:FAMILY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-446-4500
Mailing Address - Street 1:PO BOX 1010
Mailing Address - Street 2:
Mailing Address - City:ROCKDALE
Mailing Address - State:TX
Mailing Address - Zip Code:76567-1010
Mailing Address - Country:US
Mailing Address - Phone:512-446-4500
Mailing Address - Fax:
Practice Address - Street 1:1700 BRAZOS AVE
Practice Address - Street 2:
Practice Address - City:ROCKDALE
Practice Address - State:TX
Practice Address - Zip Code:76567-2517
Practice Address - Country:US
Practice Address - Phone:512-446-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX458886Medicare Oscar/Certification