1154628170 NPI number — MYCLINIC LLC

Table of content: (NPI 1154628170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154628170 NPI number — MYCLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYCLINIC 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:
MY CLINIC
Provider Other Organization Name Type Code:
3
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:
1154628170
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2440 S COLLINS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76014-1239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2440 S COLLINS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76014-1239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-537-7615
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MAESE
Authorized Official First Name:
FEDERICO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-537-7615

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  J4319 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: J4319 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: J4319 , 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: 0067CD . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 131230801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: J4319 . This is a "TEXAS STATE BOARD OF MEDICAL EXAMINERS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".