1073934055 NPI number — INTENSIVE INTEGRATION OUTPATIENT CORPORATION

Table of content: (NPI 1073934055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073934055 NPI number — INTENSIVE INTEGRATION OUTPATIENT CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTENSIVE INTEGRATION OUTPATIENT CORPORATION
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:
INTENSIVE INTEGRATION
Provider Other Organization Name Type Code:
5
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:
1073934055
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12300 HUNTERS CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLEGE STATION
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77845-7524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-690-2220
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 E PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75074-5483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-424-5659
Provider Business Practice Location Address Fax Number:
972-424-5653
Provider Enumeration Date:
12/18/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ADAMS
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
972-424-5659

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  3695-3696 , 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)





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