1386112506 NPI number — WISE CLINICAL CARE ASSOCIATES

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 1386112506 NPI number — WISE CLINICAL CARE ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WISE CLINICAL CARE ASSOCIATES
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:
1386112506
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2078
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76234-6156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-500-9636
Provider Business Mailing Address Fax Number:
817-439-8107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2432 AVONDALE HASLET RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HASLET
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76052-3446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-500-9636
Provider Business Practice Location Address Fax Number:
817-439-8107
Provider Enumeration Date:
11/06/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SCROGGINS
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
TODD
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
940-626-1228

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0047SH . This is a "BCBSTX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 389084001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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