1205105103 NPI number — GARZA THERAPEUTIC, LLC

Table of content: (NPI 1205105103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205105103 NPI number — GARZA THERAPEUTIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARZA THERAPEUTIC, 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:
GARZA THERAPEUTIC,LLC
Provider Other Organization Name Type Code:
4
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:
1205105103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 WENTWORTH AVE E
Provider Second Line Business Mailing Address:
#292
Provider Business Mailing Address City Name:
WEST ST PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55118-3431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-917-8698
Provider Business Mailing Address Fax Number:
866-879-4712

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33 E. WENTWROTH AVE.
Provider Second Line Business Practice Location Address:
#292
Provider Business Practice Location Address City Name:
WEST ST. PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-917-8698
Provider Business Practice Location Address Fax Number:
866-879-4712
Provider Enumeration Date:
12/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GARZA
Authorized Official First Name:
ROY
Authorized Official Middle Name:
Authorized Official Title or Position:
CLININCAL DIRECTOR
Authorized Official Telephone Number:
651-324-8341

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  12842 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 900002696 . This is a "MEDICARE ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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