1326004482 NPI number — SHEPHERDS GATE LIFE CHANGING CENTER

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 1326004482 NPI number — SHEPHERDS GATE LIFE CHANGING CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHEPHERDS GATE LIFE CHANGING CENTER
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:
1326004482
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 KINGFISHER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76002-3391
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-465-6522
Provider Business Mailing Address Fax Number:
817-468-7691

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
817 W PIONEER PKWY
Provider Second Line Business Practice Location Address:
SUITE 146B
Provider Business Practice Location Address City Name:
GRAND PRAIRIE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75051-4710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-522-5665
Provider Business Practice Location Address Fax Number:
972-522-5605
Provider Enumeration Date:
04/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
CHERIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/PA
Authorized Official Telephone Number:
972-522-5665

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  PA01240 , 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)





Copyright © 2007-2024 www.npivalidator.com