Provider Demographics
NPI:1902968464
Name:WACO BLUEBONNET HOLDINGS, INC.
Entity Type:Organization
Organization Name:WACO BLUEBONNET HOLDINGS, INC.
Other - Org Name:BLUEBONNET HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-772-5577
Mailing Address - Street 1:307 LONDONDERRY DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712
Mailing Address - Country:US
Mailing Address - Phone:254-751-1790
Mailing Address - Fax:
Practice Address - Street 1:307 LONDONDERRY
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7915
Practice Address - Country:US
Practice Address - Phone:254-751-1790
Practice Address - Fax:254-751-7295
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMC HEALTHCARE HOLDINGS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-14
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX010207251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001014534Medicaid
TX001014534Medicaid