1366880627 NPI number — MESA SPRINGS, LLC

Table of content: (NPI 1366880627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366880627 NPI number — MESA SPRINGS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MESA SPRINGS, LLC
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:
MESA SPRINGS
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:
1366880627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4801 OLYMPIA PARK PLZ STE 1000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40241-2090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-916-8830
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5560 MESA SPRINGS DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-292-4600
Provider Business Practice Location Address Fax Number:
817-292-4604
Provider Enumeration Date:
06/10/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LAWRENCE
Authorized Official First Name:
CHARLOTTE
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
615-920-7000

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 339487601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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