1407163660 NPI number — BRAZOS VALLEY COMMUNITY ACTION AGENCY, INC

Table of content: (NPI 1407163660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407163660 NPI number — BRAZOS VALLEY COMMUNITY ACTION AGENCY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRAZOS VALLEY COMMUNITY ACTION AGENCY, 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:
ROCK PRAIRIE FAMILY MEDICINE AND OB
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:
1407163660
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 UNIVERSITY DR E
Provider Second Line Business Mailing Address:
#100
Provider Business Mailing Address City Name:
COLLEGE STATION
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77840-2600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-846-1100
Provider Business Mailing Address Fax Number:
979-260-9390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1602 ROCK PRAIRIE RD
Provider Second Line Business Practice Location Address:
#230
Provider Business Practice Location Address City Name:
COLLEGE STATION
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77845-8308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-693-2586
Provider Business Practice Location Address Fax Number:
979-693-9047
Provider Enumeration Date:
09/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GARBER
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
979-846-1100

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 217213201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1821185299 . This is a "NPI AGENCY" identifier . This identifiers is of the category "OTHER".




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