1417069444 NPI number — PRESBYTERIAN VILLAGE NORTH FOREFRONT LIVING

Table of content: (NPI 1417069444)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417069444 NPI number — PRESBYTERIAN VILLAGE NORTH FOREFRONT LIVING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRESBYTERIAN VILLAGE NORTH FOREFRONT LIVING
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:
PRESBYTERIAN VILLAGE NORTH SPECIAL CARE CENTER
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:
1417069444
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8600 SKYLINE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75243-4198
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-355-9019
Provider Business Mailing Address Fax Number:
214-355-9050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8600 SKYLINE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75243-4198
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-355-9000
Provider Business Practice Location Address Fax Number:
214-355-9079
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON-COOK
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
KIMBERLY
Authorized Official Title or Position:
CORPORATE COMPLIANCE DIRECTOR
Authorized Official Telephone Number:
214-413-1566

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  000295 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 45D0481417 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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