1215167374 NPI number — PT2 SPORTS LLC

Table of content: (NPI 1215167374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215167374 NPI number — PT2 SPORTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PT2 SPORTS 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:
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:
1215167374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 670846
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:
75367-0846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-695-8847
Provider Business Mailing Address Fax Number:
214-239-0991

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1602 HART ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHLAKE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-695-8847
Provider Business Practice Location Address Fax Number:
214-239-0991
Provider Enumeration Date:
07/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
DALE
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
214-695-8847

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  666340000 , 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: 823T99 . This is a "BLUE CROSS BLUE SHIELD OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com