1457590549 NPI number — PINNACLE HEALTH OCCMED CLINIC, LLC

Table of content: (NPI 1457590549)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457590549 NPI number — PINNACLE HEALTH OCCMED CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINNACLE HEALTH OCCMED CLINIC, LLC
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:
Provider Other Organization Name Type Code:
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:
1457590549
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 N RAUL LONGORIA RD
Provider Second Line Business Mailing Address:
STE. P
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78589-3727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-702-4255
Provider Business Mailing Address Fax Number:
956-702-4779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 N RAUL LONGORIA RD
Provider Second Line Business Practice Location Address:
STE. P
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78589-3727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-702-4255
Provider Business Practice Location Address Fax Number:
956-702-4779
Provider Enumeration Date:
02/12/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PEREZ
Authorized Official First Name:
FRANK
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
956-702-4255

Provider Taxonomy Codes

  • Taxonomy code: 111NR0400X , with the licence number:  9416 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111NX0100X , with the licence number: 9416 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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