1396070314 NPI number — DE HEALTH LINE LLC

Table of content: (NPI 1396070314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396070314 NPI number — DE HEALTH LINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DE HEALTH LINE 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:
CEGO INFUSION SERVICES
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:
1396070314
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 571854
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77257-1854
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-541-6000
Provider Business Mailing Address Fax Number:
713-541-6001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11711 W BELLFORT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAFFORD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77477-1335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-541-6000
Provider Business Practice Location Address Fax Number:
713-541-6001
Provider Enumeration Date:
10/08/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EGBUCHUNAM
Authorized Official First Name:
GLORIA
Authorized Official Middle Name:
O
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
713-541-6000

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336H0001X , with the licence number: 26601 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 26601 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: TPI-352923201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".