1366701682 NPI number — GALENO HEALTH PA

Table of content: (NPI 1366701682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366701682 NPI number — GALENO HEALTH PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GALENO HEALTH PA
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:
LAGUNA VISTA HEALTH CLINIC
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:
1366701682
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11187
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-825-0410
Provider Business Mailing Address Fax Number:
956-825-0413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 SANTA ISABEL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGUNA VISTA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78578-2647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-825-0410
Provider Business Practice Location Address Fax Number:
956-825-0413
Provider Enumeration Date:
05/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALEZ
Authorized Official First Name:
ENRIQUE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
956-825-0410

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  P2860 , 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)





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