1164691283 NPI number — THERAPY SUPPORT, INC

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 1164691283 NPI number — THERAPY SUPPORT, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERAPY SUPPORT, INC
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:
6
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:
1164691283
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2803 N OAK GROVE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65803-4976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-887-5873
Provider Business Mailing Address Fax Number:
417-380-5205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2710 REED RD # 170
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77051-2341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-733-3803
Provider Business Practice Location Address Fax Number:
713-733-8276
Provider Enumeration Date:
02/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PAVLIN
Authorized Official First Name:
RUSCELL
Authorized Official Middle Name:
D
Authorized Official Title or Position:
3M DIRECTOR
Authorized Official Telephone Number:
417-380-5105

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  0101631 , 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: 2104879 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 160813 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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