1275836918 NPI number — KDC HEALTHCARE PARTNERS

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 1275836918 NPI number — KDC HEALTHCARE PARTNERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KDC HEALTHCARE PARTNERS
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:
6
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:
1275836918
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4605 TEXAS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75503-3028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-792-0716
Provider Business Mailing Address Fax Number:
903-792-0719

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1330 CHURCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SULPHUR SPRINGS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75482-2161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-466-3016
Provider Business Practice Location Address Fax Number:
888-702-7991
Provider Enumeration Date:
12/20/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CLEMENS
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
STAYTON
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
903-792-0716

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 020457 . This is a "TEXAS HEALTH AND HUMAN SERVICES COMMISION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 677893 . This is a "MEDICARE/PALMETTO PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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