Provider Demographics
NPI:1821185026
Name:DALLAS COUNTY MENTAL HEALTH & MENTAL RETARDATION CENTER
Entity Type:Organization
Organization Name:DALLAS COUNTY MENTAL HEALTH & MENTAL RETARDATION CENTER
Other - Org Name:DALLAS MENTAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:EDERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-743-6180
Mailing Address - Street 1:4645 SAMUELL BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-6826
Mailing Address - Country:US
Mailing Address - Phone:214-275-7393
Mailing Address - Fax:214-381-1480
Practice Address - Street 1:4645 SAMUELL BLVD STE 107
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-6826
Practice Address - Country:US
Practice Address - Phone:214-275-7393
Practice Address - Fax:214-381-1480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX64033336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2099861OtherPK