Provider Demographics
NPI:1811382948
Name:SACRED HEART PHC,LLC
Entity Type:Organization
Organization Name:SACRED HEART PHC,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:361-834-3526
Mailing Address - Street 1:103 W GRAVIS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:TX
Mailing Address - Zip Code:78384-2639
Mailing Address - Country:US
Mailing Address - Phone:361-279-8280
Mailing Address - Fax:361-279-4128
Practice Address - Street 1:103 W GRAVIS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:TX
Practice Address - Zip Code:78384-2639
Practice Address - Country:US
Practice Address - Phone:361-279-8280
Practice Address - Fax:361-279-4128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-06
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0167033747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty