1205454089 NPI number — SH OPCO BURLESON LLC

Table of content: (NPI 1205454089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205454089 NPI number — SH OPCO BURLESON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SH OPCO BURLESON 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:
COVENANT PLACE OF BURLESON
Provider Other Organization Name Type Code:
3
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:
1205454089
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14160 DALLAS PKWY STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75254-4383
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-308-8391
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 NE ALSBURY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLESON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76028-2658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-447-4477
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/08/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
DARLA
Authorized Official Middle Name:
Authorized Official Title or Position:
AR MANAGER
Authorized Official Telephone Number:
972-308-8391

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 147863 . This is a "TEXAS HELATH AND HUMAN SERVICES" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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