1841397502 NPI number — LAURENCE ROBERT BOWER III

Table of content: (NPI 1841397502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841397502 NPI number — LAURENCE ROBERT BOWER III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAURENCE ROBERT BOWER III
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:
CENTRAL TEXAS OPEN MRI
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:
1841397502
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19A GRUENE PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BRAUNFELS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78130-2484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-632-7562
Provider Business Mailing Address Fax Number:
830-632-6793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19A GRUENE PARK DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW BRAUNFELS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-606-1200
Provider Business Practice Location Address Fax Number:
830-606-1276
Provider Enumeration Date:
09/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DELEON
Authorized Official First Name:
PAULA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
830-632-7562

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , 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: 0047RG . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 364400701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".