Provider Demographics
NPI:1639245764
Name:DEPARTMENT OF STATE HEALTH SERVICES
Entity type:Organization
Organization Name:DEPARTMENT OF STATE HEALTH SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DEPUTY REGIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-778-6744
Mailing Address - Street 1:1100 W 49TH ST
Mailing Address - Street 2:HSR 7 - TEMPLE
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-3101
Mailing Address - Country:US
Mailing Address - Phone:512-458-7111
Mailing Address - Fax:
Practice Address - Street 1:2408 S 37TH ST
Practice Address - Street 2:ATTN BILLING OFFICE
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-7168
Practice Address - Country:US
Practice Address - Phone:254-778-6744
Practice Address - Fax:254-778-6819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136129704Medicaid
TX136368105Medicaid
TX136480406Medicaid
TX138359802Medicaid
TX136130503Medicaid
TX138359803Medicaid
TX133560605Medicaid
TX135248605Medicaid
TX134758503Medicaid
TXPH0243Medicare PIN
TX136368105Medicaid