1215117239 NPI number — RENJI JOHN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215117239 NPI number — RENJI JOHN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENJI JOHN
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:
ALPHA-OMEGA MEDICAL SUPPLY
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:
1215117239
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
922 MYERS MEADOW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75043-3711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-227-4353
Provider Business Mailing Address Fax Number:
214-227-5356

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3016 S SHILOH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75041-2415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-227-4353
Provider Business Practice Location Address Fax Number:
214-227-4356
Provider Enumeration Date:
11/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHN
Authorized Official First Name:
RENJI
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNNER/C.E.O
Authorized Official Telephone Number:
214-227-4353

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BX2000X , with the licence number: 0073430 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 166790901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 166790902 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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