1316987829 NPI number — SOUTHERNCARE, INC.

Table of content: (NPI 1316987829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316987829 NPI number — SOUTHERNCARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERNCARE, INC.
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:
SOUTHERNCARE DENTON
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:
1316987829
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6363 N STATE HIGHWAY 161
Provider Second Line Business Mailing Address:
SUITE 115
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75038-2269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-374-5900
Provider Business Mailing Address Fax Number:
469-374-5901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5800 N I35
Provider Second Line Business Practice Location Address:
STE 200 B
Provider Business Practice Location Address City Name:
DENTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76207-1438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-243-0901
Provider Business Practice Location Address Fax Number:
940-243-0904
Provider Enumeration Date:
06/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PRIEST
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CHIEF COMPLIANCE OFFICER
Authorized Official Telephone Number:
469-374-5914

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  015010 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001013519 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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