Provider Demographics
NPI:1265648927
Name:ROCKDALE BLACKHAWK LLC
Entity type:Organization
Organization Name:ROCKDALE BLACKHAWK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR, INSURANCE CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-446-4500
Mailing Address - Street 1:PO BOX 1010
Mailing Address - Street 2:
Mailing Address - City:ROCKDALE
Mailing Address - State:TX
Mailing Address - Zip Code:76567-1010
Mailing Address - Country:US
Mailing Address - Phone:512-446-4500
Mailing Address - Fax:512-446-2063
Practice Address - Street 1:1700 BRAZOS AVE
Practice Address - Street 2:
Practice Address - City:ROCKDALE
Practice Address - State:TX
Practice Address - Zip Code:76567-2517
Practice Address - Country:US
Practice Address - Phone:512-445-4500
Practice Address - Fax:512-446-2063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000369332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies