Provider Demographics
NPI:1912599838
Name:INNATE HOSPITAL LLC
Entity Type:Organization
Organization Name:INNATE HOSPITAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC MD
Authorized Official - Phone:469-215-3494
Mailing Address - Street 1:707 N WALDRIP ST
Mailing Address - Street 2:
Mailing Address - City:GRAND SALINE
Mailing Address - State:TX
Mailing Address - Zip Code:75140-1555
Mailing Address - Country:US
Mailing Address - Phone:903-913-6303
Mailing Address - Fax:
Practice Address - Street 1:707 N WALDRIP ST
Practice Address - Street 2:
Practice Address - City:GRAND SALINE
Practice Address - State:TX
Practice Address - Zip Code:75140-1555
Practice Address - Country:US
Practice Address - Phone:903-913-6303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit