1083911622 NPI number — LITTLE ELM FRISCO CHILDREN'S CLINIC

Table of content: (NPI 1083911622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083911622 NPI number — LITTLE ELM FRISCO CHILDREN'S CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LITTLE ELM FRISCO CHILDREN'S CLINIC
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:
1083911622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12398 FM 423
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
FRISCO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75033-0158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-494-4622
Provider Business Mailing Address Fax Number:
214-494-4609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12398 FM 423
Provider Second Line Business Practice Location Address:
SUITE 600
Provider Business Practice Location Address City Name:
FRISCO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75033-0158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-494-4622
Provider Business Practice Location Address Fax Number:
214-494-4609
Provider Enumeration Date:
02/17/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GUPTA
Authorized Official First Name:
PREM
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
214-494-4622

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  F7772 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: F8878 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 24778 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 126877306 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 220282201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 133070608 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 220282202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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