1114976560 NPI number — VIS PROCEDURE CENTER, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114976560 NPI number — VIS PROCEDURE CENTER, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIS PROCEDURE CENTER, PA
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:
1114976560
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2040 N LOOP 336 W
Provider Second Line Business Mailing Address:
SUITE 314
Provider Business Mailing Address City Name:
CONROE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77304-3500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-539-6497
Provider Business Mailing Address Fax Number:
936-539-4612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MEDICAL CENTER BLVD
Provider Second Line Business Practice Location Address:
SUITE 118
Provider Business Practice Location Address City Name:
CONROE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77304-2888
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-539-4031
Provider Business Practice Location Address Fax Number:
936-539-4537
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TURLEY
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
RAYNIOR
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
936-539-4031

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  K3506 , 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: 0071NE . This is a "BLUE CROSS BLUE SHIELD TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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