1205113347 NPI number — RANCH 2300

Table of content: (NPI 1205113347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205113347 NPI number — RANCH 2300

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RANCH 2300
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:
1205113347
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2535 E SOUTHLAKE BLVD STE 220
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:
76092-6629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-310-0379
Provider Business Mailing Address Fax Number:
817-310-1086

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11609 N COUNTY ROAD 2300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79403-6751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-746-6777
Provider Business Practice Location Address Fax Number:
817-310-1086
Provider Enumeration Date:
11/03/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GILBERT
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF LEGAL OFFICER
Authorized Official Telephone Number:
615-716-4924

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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