1700028289 NPI number — CALDWELL II ENTERPRISES, LLC

Table of content: EMILY FRAZIER (NPI 1497539639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700028289 NPI number — CALDWELL II ENTERPRISES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CALDWELL II ENTERPRISES, 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:
COPPERAS HOLLOW NURSING & REHABILITATION CENTER
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:
1700028289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
345 COUNTRY CLUB DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALDWELL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77836-2328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-567-4300
Provider Business Mailing Address Fax Number:
979-567-4315

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
345 COUNTRY CLUB DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77836-2328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-567-4300
Provider Business Practice Location Address Fax Number:
979-567-4315
Provider Enumeration Date:
03/31/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BLAKE
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
817-348-8841

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001017065 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com