1366611725 NPI number — EAST TEXAS CASE MANAGEMENT REFERRAL SERVICE

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 1366611725 NPI number — EAST TEXAS CASE MANAGEMENT REFERRAL SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS CASE MANAGEMENT REFERRAL SERVICE
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:
1366611725
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2300 BILL OWENS PKWY
Provider Second Line Business Mailing Address:
915
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75604-3033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-295-0098
Provider Business Mailing Address Fax Number:
903-295-0098

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 BILL OWENS PARKWAY
Provider Second Line Business Practice Location Address:
915
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-295-0098
Provider Business Practice Location Address Fax Number:
903-295-0098
Provider Enumeration Date:
02/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR/OWNER/CASE MANAGER
Authorized Official Telephone Number:
903-295-0098

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  26290 , 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: 251B00000X , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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