1619089216 NPI number — BANDERA FAMILY HEALTH CARE, P. A.

Table of content: (NPI 1619089216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619089216 NPI number — BANDERA FAMILY HEALTH CARE, P. A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BANDERA FAMILY HEALTH CARE, P. A.
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:
1619089216
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 268945
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73126-8945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-695-1900
Provider Business Mailing Address Fax Number:
210-695-1901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7579 N LOOP 1604 W
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78249-2781
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-695-1900
Provider Business Practice Location Address Fax Number:
210-695-1901
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REYES
Authorized Official First Name:
RAMON
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
210-695-1900

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  J1367 , 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: 0024QF . This is a "BC/BS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 188611102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 188611101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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