1063088102 NPI number — PRACTITIONERS WITHOUT WALLS, LLC

Table of content: (NPI 1063088102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063088102 NPI number — PRACTITIONERS WITHOUT WALLS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRACTITIONERS WITHOUT WALLS, 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:
1063088102
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5554 S PEEK RD UNIT 2102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KATY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77450-7130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-896-0888
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21802 SILVERPEAK CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KATY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77450-5622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-896-0888
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OLUKOYA
Authorized Official First Name:
FUNMI
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
281-896-0888

Provider Taxonomy Codes

  • Taxonomy code: 261QF0050X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1629307202 . This is a "NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".