1417108960 NPI number — ASP CENTERS FOR DIABETIC MANAGEMENT, LLC

Table of content: (NPI 1417108960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417108960 NPI number — ASP CENTERS FOR DIABETIC MANAGEMENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASP CENTERS FOR DIABETIC MANAGEMENT, 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:
Provider Other Organization Name Type Code:
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:
1417108960
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3040 POST OAK BLVD
Provider Second Line Business Mailing Address:
SUITE 1230
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77056-6500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-554-7500
Provider Business Mailing Address Fax Number:
713-554-7510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 MEDICAL PARK LN
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
HUNTSVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77340-4978
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-554-7500
Provider Business Practice Location Address Fax Number:
713-554-7510
Provider Enumeration Date:
10/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MANTZOROS
Authorized Official First Name:
DIMITRIOS
Authorized Official Middle Name:
Authorized Official Title or Position:
DPM, PARTNER
Authorized Official Telephone Number:
281-298-6665

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  1068 , 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)





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