1285668541 NPI number — GULF BEND MRMR CENTER HCS PROGRAM

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 1285668541 NPI number — GULF BEND MRMR CENTER HCS PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GULF BEND MRMR CENTER HCS PROGRAM
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:
1285668541
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6502 NURSERY DR.
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
VICTORIA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77904-4112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-575-0611
Provider Business Mailing Address Fax Number:
361-582-2329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6502 NURSERY DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
VICTORIA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77904-1178
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-575-0611
Provider Business Practice Location Address Fax Number:
361-582-2323
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POLZIN
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
L
Authorized Official Title or Position:
EXECUTIVE DIRECOTR
Authorized Official Telephone Number:
361-575-0611

Provider Taxonomy Codes

  • Taxonomy code: 320900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001007430 . This is a "CONTRACT NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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