1053667626 NPI number — NICOLE BRINTS-VINER PT

Table of content: NICOLE BRINTS-VINER PT (NPI 1053667626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053667626 NPI number — NICOLE BRINTS-VINER PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRINTS-VINER
Provider First Name:
NICOLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

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:
1053667626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2431 S LOOP 289
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79423-1519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-771-8008
Provider Business Mailing Address Fax Number:
806-771-8009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4138 19TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79407-2403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-780-2329
Provider Business Practice Location Address Fax Number:
806-780-2330
Provider Enumeration Date:
08/01/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1218341 , 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: 307091402 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01550212 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 307091401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 878T95 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 540041100 . This is a "FIRSTCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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