1033566286 NPI number — WALK-IN CLINIC, LLC

Table of content: JAVED H. FAZAL M.D. (NPI 1942243704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033566286 NPI number — WALK-IN CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALK-IN CLINIC, LLC
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:
1033566286
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 633821
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NACOGDOCHES
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75963-3821
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-564-7373
Provider Business Mailing Address Fax Number:
936-564-9338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1516 S 31ST ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
TEMPLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76504-6752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-778-6626
Provider Business Practice Location Address Fax Number:
254-221-8079
Provider Enumeration Date:
05/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHUM
Authorized Official First Name:
RAYBURN
Authorized Official Middle Name:
WESLEY
Authorized Official Title or Position:
DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official Telephone Number:
936-553-3417

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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