1972684637 NPI number — SKELETAL DIAGNOSTICS OF SEALY

Table of content: (NPI 1972684637)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972684637 NPI number — SKELETAL DIAGNOSTICS OF SEALY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SKELETAL DIAGNOSTICS OF SEALY
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:
1972684637
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 945
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77418-0945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-865-3124
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
526 WARD ST
Provider Second Line Business Practice Location Address:
SUITE 135
Provider Business Practice Location Address City Name:
SEALY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77474-2651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-352-4983
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ABEL
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER/TECHNICIAN
Authorized Official Telephone Number:
281-352-4983

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 080922001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0063BR . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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