Provider Demographics
NPI:1881778025
Name:HEART OF TEXAS REGION MENTAL HEALTH MENTAL RETARDATION CENTER
Entity type:Organization
Organization Name:HEART OF TEXAS REGION MENTAL HEALTH MENTAL RETARDATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-752-3451
Mailing Address - Street 1:110 S 12TH ST
Mailing Address - Street 2:P O BOX
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76701-1810
Mailing Address - Country:US
Mailing Address - Phone:254-752-3451
Mailing Address - Fax:254-752-7421
Practice Address - Street 1:3420 W WACO DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5437
Practice Address - Country:US
Practice Address - Phone:254-757-3933
Practice Address - Fax:254-752-1931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111409201Medicaid