1356433189 NPI number — COVENANT PLACE OF ABILENE

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 1356433189 NPI number — COVENANT PLACE OF ABILENE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENANT PLACE OF ABILENE
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:
1356433189
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14160 DALLAS PKWY
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75254-4319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-770-5600
Provider Business Mailing Address Fax Number:
972-770-5666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3234 BUFFALO GAP RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABILENE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79605-7009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-793-1144
Provider Business Practice Location Address Fax Number:
325-793-1422
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHANNESSEN
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT & COO
Authorized Official Telephone Number:
972-770-5600

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  117839 , 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: 001014103 . This is a "TEXAS CBA CONTRACT #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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