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PED453302-09 CHILDREN'S MEDICAL CENTER DALLAS (Terminated)
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Main Details
Name
CHILDREN'S MEDICAL CENTER DALLAS
Subdivision Name
CHILDREN'S AMBULATORY SURGERY CENTER AT SOUTHLAKE
Type
Children's Hospital
Rural
No
340B ID
PED453302-09
Medicare Provider Number
453302
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
8/3/2011
Participating Start Date
1/1/2012
Participating Approval Date
11/29/2011
Last Recertification Date
8/7/2015
Termination Date
Termination Reason
4/1/2016
Site closure
Contacts
Authorizing Official
Children's Health
David T Berry, CHST President, System Clinical Operations
(214) 456-2143
Primary Contact
Children's Health
Sandra K. Howell, Pharmacy Manager
(214) 456-0422
Addresses
Street Address
470 E STATE HIGHWAY 114
SOUTHLAKE, TX 76092
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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