1114234002 NPI number — STACY TRIMBLE GRAZAK P.T.

Table of content: STACY TRIMBLE GRAZAK P.T. (NPI 1114234002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114234002 NPI number — STACY TRIMBLE GRAZAK P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAZAK
Provider First Name:
STACY
Provider Middle Name:
TRIMBLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TRIMBLE
Provider Other First Name:
STACY
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114234002
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3801 VISTA RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77504-2159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-910-5437
Provider Business Mailing Address Fax Number:
713-910-5445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3801 VISTA RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77504-2159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-910-5437
Provider Business Practice Location Address Fax Number:
713-910-5445
Provider Enumeration Date:
09/13/2010

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: 225100000X , with the licence number:  1197140 , 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)