1053526624 NPI number — PROCARE HEALING CENTERS, LLP

Table of content: (NPI 1053526624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053526624 NPI number — PROCARE HEALING CENTERS, LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROCARE HEALING CENTERS, LLP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
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Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053526624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6307 WATERFORD BLVD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73118-1125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-608-0350
Provider Business Mailing Address Fax Number:
405-608-0349

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2519 S. LAKELINE BOULEVARD
Provider Second Line Business Practice Location Address:
UNIT 101
Provider Business Practice Location Address City Name:
CEDAR PARK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-249-9498
Provider Business Practice Location Address Fax Number:
512-608-9268
Provider Enumeration Date:
05/14/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DEVILLIERS
Authorized Official First Name:
GAIL
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
405-608-0350

Provider Taxonomy Codes

  • Taxonomy code: 261QS1200X , 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)