1174164743 NPI number — UNANCHORED MINDS LLC

Table of content: (NPI 1174164743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174164743 NPI number — UNANCHORED MINDS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNANCHORED MINDS 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:
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:
1174164743
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5269 FM 580 E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEMPNER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76539-8754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-734-3940
Provider Business Mailing Address Fax Number:
512-887-1254

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 E 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAMPASAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76550-2910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-734-3940
Provider Business Practice Location Address Fax Number:
512-887-1254
Provider Enumeration Date:
10/03/2019

Additional Information

Authorized Official

Authorized Official Last Name:
CASE
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
512-734-3940

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 79796 . This is a "LPC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 14512 . This is a "LCDC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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