1275716110 NPI number — URBAN HEALTHCARE, LLC

Table of content: (NPI 1275716110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275716110 NPI number — URBAN HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
URBAN HEALTHCARE, 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:
SANTA CLARA FAMILY CLINIC
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:
1275716110
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2837 CLINTON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77020-8401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-923-2273
Provider Business Mailing Address Fax Number:
713-923-2276

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5616 LAWNDALE ST
Provider Second Line Business Practice Location Address:
SUITE A-203
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77023-3840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-923-2273
Provider Business Practice Location Address Fax Number:
713-923-2276
Provider Enumeration Date:
12/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
URTIS
Authorized Official First Name:
JASON
Authorized Official Middle Name:
T
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
713-923-2273

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 192241102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0011RB . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 192241101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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