1467770073 NPI number — GRILL REPAIR PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467770073 NPI number — GRILL REPAIR PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRILL REPAIR 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:
RED RIVER ORTHODONTICS
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:
1467770073
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7134 CAMPBELL RD STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75248-1564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-522-3306
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 EUREKA CIR STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA FALLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76308-2929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-522-3306
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ELVEBAK
Authorized Official First Name:
BRYNA
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
469-522-3306

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  20522 , 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)