1437317294 NPI number — UGARTE FAMILY MEDICAL CLINIC PA

Table of content: (NPI 1437317294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437317294 NPI number — UGARTE FAMILY MEDICAL CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UGARTE FAMILY MEDICAL CLINIC PA
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:
JOSE MANUEL UGARTE
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:
1437317294
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1557
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78364-1557
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-221-1087
Provider Business Mailing Address Fax Number:
361-488-5030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1311 E GENERAL CAVAZOS BLVD STE L
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-221-1087
Provider Business Practice Location Address Fax Number:
361-488-5030
Provider Enumeration Date:
05/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
UGARTE
Authorized Official First Name:
JOSE
Authorized Official Middle Name:
MANUEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
361-221-1087

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  E3134 , 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)

  • Identifier: 136466303 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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