1043554322 NPI number — MARY GUADALUPE TREVINO COTA

Table of content: MARY GUADALUPE TREVINO COTA (NPI 1043554322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043554322 NPI number — MARY GUADALUPE TREVINO COTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TREVINO
Provider First Name:
MARY
Provider Middle Name:
GUADALUPE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
COTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043554322
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
305 NE LOOP 280
Provider Second Line Business Mailing Address:
BUISNESS TOWER 1, SUITE 200
Provider Business Mailing Address City Name:
HURST
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-292-8787
Provider Business Mailing Address Fax Number:
817-789-6849

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17480 DALLAS PKWY
Provider Second Line Business Practice Location Address:
SUITE 221
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75287-7337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-623-5900
Provider Business Practice Location Address Fax Number:
214-623-5901
Provider Enumeration Date:
11/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 224Z00000X , with the licence number: 211874 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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