1013176114 NPI number — WISDOM HEALTHCARE CLINIC N HEALTHCARE SERVICES INC

Table of content: (NPI 1013176114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013176114 NPI number — WISDOM HEALTHCARE CLINIC N HEALTHCARE SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WISDOM HEALTHCARE CLINIC N HEALTHCARE SERVICES 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:
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:
1013176114
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
403 W MAIN ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
LEWISVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75057-3757
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-200-6189
Provider Business Mailing Address Fax Number:
469-464-4398

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
403 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LEWISVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75057-3757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-200-6189
Provider Business Practice Location Address Fax Number:
469-464-4398
Provider Enumeration Date:
06/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BADEJO
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
972-436-1811

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  PA04564 , 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: 198899001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1067786 . This is a "NCCPA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: PA04564 . This is a "LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com