1851478309 NPI number — CUSTOM CARE TEAM, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851478309 NPI number — CUSTOM CARE TEAM, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUSTOM CARE TEAM, INC.
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:
THE MEDICAL TEAM PERSONAL CARE SERVICES
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:
1851478309
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
45 NE LOOP 410 STE 800
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78216-5837
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-227-9000
Provider Business Mailing Address Fax Number:
210-224-2020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1806 W STASSNEY LN STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78745-3645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-985-9058
Provider Business Practice Location Address Fax Number:
512-985-9343
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
ANGIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CORP AR MANAGER
Authorized Official Telephone Number:
210-227-9000

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3747P1801X , with the licence number: 007838 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 389094901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001027364 . This is a "COMMUNITY CARE CONTRACT NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 007838 . This is a "STATE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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