1194745943 NPI number — GEMINI CONCEPTS, INC

Table of content: (NPI 1194745943)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194745943 NPI number — GEMINI CONCEPTS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEMINI CONCEPTS, 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:
BACK IN ACTION SPINAL DECOMPRESSION CENTER
Provider Other Organization Name Type Code:
5
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:
1194745943
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 92248
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHLAKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76092-0103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-421-9111
Provider Business Mailing Address Fax Number:
817-421-9222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
680 N CARROLL AVE
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
SOUTHLAKE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76092-6475
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-421-9111
Provider Business Practice Location Address Fax Number:
817-421-9222
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIDOVICH
Authorized Official First Name:
GREG
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
817-421-9111

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  6658 , 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: 0005ND . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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