1275641458 NPI number — GRACE CARE OF TEXAS

Table of content: (NPI 1275641458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275641458 NPI number — GRACE CARE OF TEXAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACE CARE OF TEXAS
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:
COMMUNITY CARE CENTER OF CROCKETT
Provider Other Organization Name Type Code:
3
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:
1275641458
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:
505 W CENTERVILLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75041-5445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-278-3566
Provider Business Mailing Address Fax Number:
972-840-0888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1150 E LOOP 304
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROCKETT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75835-1810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-544-2051
Provider Business Practice Location Address Fax Number:
936-544-8981
Provider Enumeration Date:
08/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CROWSON
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
O
Authorized Official Title or Position:
RECEIVERSHIP
Authorized Official Telephone Number:
972-278-3566

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  4802 , 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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