1790700680 NPI number — LILLIAN M COOVER PA

Table of content: LILLIAN M COOVER PA (NPI 1790700680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790700680 NPI number — LILLIAN M COOVER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOVER
Provider First Name:
LILLIAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

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:
1790700680
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2046 FOREST LN
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
GARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75042-7958
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-494-4494
Provider Business Mailing Address Fax Number:
972-494-4450

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3228 I-30
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MESQUITE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75150-2633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-216-5400
Provider Business Practice Location Address Fax Number:
972-216-5405
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA02299 , 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: 182461701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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