Provider Demographics
NPI:1629062369
Name:DALLAS COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:DALLAS COUNTY HOSPITAL DISTRICT
Other - Org Name:WILLIAMSBURG VILLAGE HEALTHCARE CAMPUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:CERISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-590-8006
Mailing Address - Street 1:1500 WATERS RIDGE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-6011
Mailing Address - Country:US
Mailing Address - Phone:972-899-4401
Mailing Address - Fax:972-899-4460
Practice Address - Street 1:940 YORK DR
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2042
Practice Address - Country:US
Practice Address - Phone:972-572-6200
Practice Address - Fax:972-572-9365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112098314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164055901OtherMEDICAID CO B
TX001026661Medicaid
TX001004882Medicaid
TX001004882Medicaid