1619112612 NPI number — DEER OAKS SOUTHEAST LLC

Table of content: (NPI 1619112612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619112612 NPI number — DEER OAKS SOUTHEAST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEER OAKS SOUTHEAST 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:
1619112612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7272 WURZBACH RD
Provider Second Line Business Mailing Address:
SUITE 601
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78240-4801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-365-6271
Provider Business Mailing Address Fax Number:
210-593-9863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7272 WURZBACH RD
Provider Second Line Business Practice Location Address:
SUITE 601
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78240-4801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-615-8880
Provider Business Practice Location Address Fax Number:
210-593-9863
Provider Enumeration Date:
12/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BOSKIND
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
888-365-6271

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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