1407967599 NPI number — WEST TEXAS A&M UNIVERSITY STUDENT MEDICAL SERVICES

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 1407967599 NPI number — WEST TEXAS A&M UNIVERSITY STUDENT MEDICAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST TEXAS A&M UNIVERSITY STUDENT MEDICAL SERVICES
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:
1407967599
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
WTAMU PO BOX 61401
Provider Second Line Business Mailing Address:
WEST TEXAS A&M UNIVERSITY STUDENT MEDICAL SERVICES
Provider Business Mailing Address City Name:
CANYON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79016-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-651-3287
Provider Business Mailing Address Fax Number:
806-651-3289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2620 N RUSSEL LONG BLVD
Provider Second Line Business Practice Location Address:
VIRGIL HENSON ACTIVITIES CENTER ROOM 104
Provider Business Practice Location Address City Name:
CANYON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79016-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-651-3287
Provider Business Practice Location Address Fax Number:
806-651-3289
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RICKWARTZ
Authorized Official First Name:
LUANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
806-651-3287

Provider Taxonomy Codes

  • Taxonomy code: 261QS1000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 91914669 . This is a "TPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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