1396220604 NPI number — TMC MANSFIELD, LLC

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 1396220604 NPI number — TMC MANSFIELD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TMC MANSFIELD, 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:
1710 MANSFIELD MEDICAL GROUP
Provider Other Organization Name Type Code:
4
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:
1396220604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1845 PRECINCT LINE RD STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HURST
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76054-3109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-294-9666
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1710 HIGHWAY 287 N STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76063-7631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-294-9666
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/02/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GUERRERO
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
972-294-9666

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 284300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 802982535 . This is a "STATE FILE NUMBER - SECRETARY OF STATE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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