1962516955 NPI number — THE MEDICINE PLACE INC 1008 LAMAR ST SWEETWATER TX

Table of content: (NPI 1962516955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962516955 NPI number — THE MEDICINE PLACE INC 1008 LAMAR ST SWEETWATER TX

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE MEDICINE PLACE INC 1008 LAMAR ST SWEETWATER TX
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 MEDICINE PLACE
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:
1962516955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1410 LAMAR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SWEETWATER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79556-7124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-236-6809
Provider Business Mailing Address Fax Number:
325-236-6800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1410 LAMAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SWEETWATER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79556-7124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-236-6809
Provider Business Practice Location Address Fax Number:
325-236-6800
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BASYE
Authorized Official First Name:
TEDDY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
325-236-6809

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 10620 , 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: 142643 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4566886 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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