1083856512 NPI number — KIDNEY DISEASE SPECIALISTS OF WEST TEXAS PA

Table of content: (NPI 1083856512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083856512 NPI number — KIDNEY DISEASE SPECIALISTS OF WEST TEXAS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDNEY DISEASE SPECIALISTS OF WEST TEXAS PA
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:
LARRY A WARMOTH MD PRESIDENT
Provider Other Organization Name Type Code:
5
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:
1083856512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5109 82ND ST
Provider Second Line Business Mailing Address:
STE 7 #1114
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79424-3028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-798-1594
Provider Business Mailing Address Fax Number:
806-794-0125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3801 21ST ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79410-1006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-687-0338
Provider Business Practice Location Address Fax Number:
806-687-4326
Provider Enumeration Date:
03/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SCHMIDT
Authorized Official First Name:
ANDREA
Authorized Official Middle Name:
G
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
806-798-1594

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  J4599 , 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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