Provider Demographics
NPI:1811339831
Name:ROCKDALE BLACKHAWK LLC
Entity type:Organization
Organization Name:ROCKDALE BLACKHAWK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:P
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-446-4500
Mailing Address - Street 1:1904 RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-7718
Mailing Address - Country:US
Mailing Address - Phone:512-863-4563
Mailing Address - Fax:512-869-5899
Practice Address - Street 1:1904 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7718
Practice Address - Country:US
Practice Address - Phone:512-863-4563
Practice Address - Fax:512-869-5899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier