1710015201 NPI number — ANDERSON CHEROKEE COMMUNITY ENRICHMENT SERVICES

Table of content: (NPI 1710015201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710015201 NPI number — ANDERSON CHEROKEE COMMUNITY ENRICHMENT SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDERSON CHEROKEE COMMUNITY ENRICHMENT SERVICES
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:
ACCESS
Provider Other Organization Name Type Code:
5
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:
1710015201
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1011 COLLEGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75766-3307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-589-9000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 COLLEGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-589-9000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STROM
Authorized Official First Name:
DIANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
REIMBURSEMENT COORDINATOR
Authorized Official Telephone Number:
903-589-9000

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  17029 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 63332 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WC1500X , with the licence number: 674004 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WC1500X , with the licence number: 618031 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 164X00000X , with the licence number: 051913 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: H5197 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: K2150 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00T09Z . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 111411803 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".