Provider Demographics
NPI:1811489974
Name:ROCKDALE BLACKHAWK, LLC
Entity type:Organization
Organization Name:ROCKDALE BLACKHAWK, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:BORGFELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-446-4502
Mailing Address - Street 1:1700 BRAZOS AVENUE
Mailing Address - Street 2:
Mailing Address - City:ROCKDALE
Mailing Address - State:TX
Mailing Address - Zip Code:76567
Mailing Address - Country:US
Mailing Address - Phone:512-446-4500
Mailing Address - Fax:512-446-0084
Practice Address - Street 1:1909 SW HK DODGEN LOOP
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502
Practice Address - Country:US
Practice Address - Phone:254-298-2530
Practice Address - Fax:254-777-0207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130224261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical