Provider Demographics
NPI:1821214537
Name:SABINE VALLEY REGIONAL MHMR CENTER
Entity Type:Organization
Organization Name:SABINE VALLEY REGIONAL MHMR CENTER
Other - Org Name:EARLY CHILDHOOD INTERVENTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:O
Authorized Official - Last Name:VILLARREAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-234-4226
Mailing Address - Street 1:107 WOODBINE PL UNIT 775
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-2912
Mailing Address - Country:US
Mailing Address - Phone:903-918-5806
Mailing Address - Fax:903-295-5803
Practice Address - Street 1:107 WOODBINE PL UNIT 775
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-2912
Practice Address - Country:US
Practice Address - Phone:903-918-5806
Practice Address - Fax:903-295-5803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137921605Medicaid