1205112570 NPI number — WANDA E MURGA LCDC

Table of content: WANDA E MURGA LCDC (NPI 1205112570)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205112570 NPI number — WANDA E MURGA LCDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MURGA
Provider First Name:
WANDA
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCDC
Provider Gender Code:
F

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:
1205112570
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
239 S VIRGINIA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STEPHENVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76401-4344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-965-5515
Provider Business Mailing Address Fax Number:
254-965-7416

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2111 W HWY 377
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANBURY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76048-5627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-573-6002
Provider Business Practice Location Address Fax Number:
817-573-6009
Provider Enumeration Date:
10/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  11075 , 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: 148686201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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