1861615528 NPI number — REBECCA HOLM PAC

Table of content: REBECCA HOLM PAC (NPI 1861615528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861615528 NPI number — REBECCA HOLM PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLM
Provider First Name:
REBECCA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KONEN
Provider Other First Name:
REBECCA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1861615528
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10011 WINDLEDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75238-2148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-733-2281
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2222 WELBORN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75219-3924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-559-7830
Provider Business Practice Location Address Fax Number:
214-559-8383
Provider Enumeration Date:
04/11/2007

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:  PA03306 , 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: PA03306 . This is a "LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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