1407967599 NPI number — WEST TEXAS A&M UNIVERSITY STUDENT MEDICAL SERVICES

Table of content: (NPI 1407967599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407967599 NPI number — WEST TEXAS A&M UNIVERSITY STUDENT MEDICAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST TEXAS A&M UNIVERSITY STUDENT MEDICAL SERVICES
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:
STUDENT MEDICAL SERVICES
Provider Other Organization Name Type Code:
4
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:
1407967599
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
WTAMU PO BOX 61401
Provider Second Line Business Mailing Address:
WEST TEXAS A&M UNIVERSITY STUDENT MEDICAL SERVICES
Provider Business Mailing Address City Name:
CANYON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79016-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-651-3287
Provider Business Mailing Address Fax Number:
806-651-3289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2620 N RUSSEL LONG BLVD
Provider Second Line Business Practice Location Address:
VIRGIL HENSON ACTIVITIES CENTER ROOM 104
Provider Business Practice Location Address City Name:
CANYON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79016-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-651-3287
Provider Business Practice Location Address Fax Number:
806-651-3289
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RICKWARTZ
Authorized Official First Name:
LUANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
806-651-3287

Provider Taxonomy Codes

  • Taxonomy code: 261QS1000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 91914669 . This is a "TPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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