1245771963 NPI number — TEXAS HEALTHY AGING AND HORMONE THERAPY LLC

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 1245771963 NPI number — TEXAS HEALTHY AGING AND HORMONE THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEXAS HEALTHY AGING AND HORMONE THERAPY 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:
1245771963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 SW 25TH AVE
Provider Second Line Business Mailing Address:
SUITE 1200
Provider Business Mailing Address City Name:
MINERAL WELLS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76067-8298
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-325-3706
Provider Business Mailing Address Fax Number:
940-325-6200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 SW 25TH AVE
Provider Second Line Business Practice Location Address:
SUITE 1200
Provider Business Practice Location Address City Name:
MINERAL WELLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76067-8298
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-325-3706
Provider Business Practice Location Address Fax Number:
940-325-6200
Provider Enumeration Date:
03/14/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HOPPER
Authorized Official First Name:
LORI
Authorized Official Middle Name:
SHAE
Authorized Official Title or Position:
SOLE MBR
Authorized Official Telephone Number:
940-325-3706

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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