1962638023 NPI number — FAIRMONT INFUSION CENTER, PLLC

Table of content: (NPI 1962638023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962638023 NPI number — FAIRMONT INFUSION CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRMONT INFUSION CENTER, PLLC
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:
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:
1962638023
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5187
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77508-5187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-998-8109
Provider Business Mailing Address Fax Number:
281-487-0812

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4001 PRESTON AVE
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77505-2069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-998-8109
Provider Business Practice Location Address Fax Number:
281-487-0812
Provider Enumeration Date:
06/03/2009

Additional Information

Authorized Official

Authorized Official Last Name:
FEIN
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
281-998-8109

Provider Taxonomy Codes

  • Taxonomy code: 261QI0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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