1255760054 NPI number — QUALITY ACUTE CARE, PA

Table of content: (NPI 1255760054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255760054 NPI number — QUALITY ACUTE CARE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUALITY ACUTE CARE, PA
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:
MAIN STREET URGENT CARE
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:
1255760054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1421 S MAIN ST
Provider Second Line Business Mailing Address:
SUITE #111
Provider Business Mailing Address City Name:
BOERNE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78006-3321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-249-9995
Provider Business Mailing Address Fax Number:
830-249-9868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1421 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE #111
Provider Business Practice Location Address City Name:
BOERNE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78006-3321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-249-9995
Provider Business Practice Location Address Fax Number:
830-249-9868
Provider Enumeration Date:
11/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DEDMON
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
THURMOND
Authorized Official Title or Position:
ADMINISTRATIVE MANAGER
Authorized Official Telephone Number:
830-249-9995

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  K8182 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: PA02389 , 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: 342847601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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