Provider Demographics
NPI:1821204611
Name:LAKES REGIONAL MENTAL HEALTH MENTAL RETARDATION CENTER
Entity Type:Organization
Organization Name:LAKES REGIONAL MENTAL HEALTH MENTAL RETARDATION CENTER
Other - Org Name:LAKES REGIONAL COMMUNITY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ERWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-524-4159
Mailing Address - Street 1:400 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:TERRELL
Mailing Address - State:TX
Mailing Address - Zip Code:75160-4302
Mailing Address - Country:US
Mailing Address - Phone:972-524-4159
Mailing Address - Fax:972-388-2009
Practice Address - Street 1:400 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:TERRELL
Practice Address - State:TX
Practice Address - Zip Code:75160-4302
Practice Address - Country:US
Practice Address - Phone:972-524-4159
Practice Address - Fax:972-388-2009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121988303Medicaid