1346333036 NPI number — BROUGHTON ENTERPRISES INC

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 1346333036 NPI number — BROUGHTON ENTERPRISES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROUGHTON ENTERPRISES 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:
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:
1346333036
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
905 S JOHN REDDITT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUFKIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75904-4326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-632-1119
Provider Business Mailing Address Fax Number:
936-637-7811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
905 S JOHN REDDITT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUFKIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75904-4326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-632-1119
Provider Business Practice Location Address Fax Number:
936-637-7811
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROUGHTON
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
BOOKKEEPER
Authorized Official Telephone Number:
936-632-1119

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 16081 . This is a "PROVIDER ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 066437701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 23154 . This is a "PROVIDER ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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