1285057935 NPI number — LEGACY HEART CARE OF SAN ANTONIO

Table of content: (NPI 1285057935)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285057935 NPI number — LEGACY HEART CARE OF SAN ANTONIO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEGACY HEART CARE OF SAN ANTONIO
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:
FLOW THERAPY SAN ANTONIO
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:
1285057935
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 WEST FWY
Provider Second Line Business Mailing Address:
200
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76102-5848
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-423-4400
Provider Business Mailing Address Fax Number:
817-423-8080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 SPURS LN STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78240-1761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-423-4400
Provider Business Practice Location Address Fax Number:
817-423-8080
Provider Enumeration Date:
01/31/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRATCH
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
817-423-4400

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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