1124139340 NPI number — PREMIANT INC

Table of content: (NPI 1124139340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124139340 NPI number — PREMIANT INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIANT INC
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:
TRAVIS HOUSE
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:
1124139340
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:
1110 WEST WILLIAM CANNON
Provider Second Line Business Mailing Address:
BUILDING 2
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-916-1632
Provider Business Mailing Address Fax Number:
512-916-1639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9112 JAPONICA COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-916-1632
Provider Business Practice Location Address Fax Number:
512-916-1639
Provider Enumeration Date:
08/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LATIMER
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
512-916-1632

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  3639 , 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)