1417598673 NPI number — JULIA LARSEN PLCC, CORPORATION

Table of content: DR. PRIYA RUDOLPH MD, PHD (NPI 1871587113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417598673 NPI number — JULIA LARSEN PLCC, CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JULIA LARSEN PLCC, CORPORATION
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:
1417598673
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 MCKINNEY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMERSVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75442-2213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-784-3064
Provider Business Mailing Address Fax Number:
972-784-3069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 MCKINNEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMERSVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75442-2213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-784-3064
Provider Business Practice Location Address Fax Number:
972-784-3069
Provider Enumeration Date:
09/30/2019

Additional Information

Authorized Official

Authorized Official Last Name:
LARSEN
Authorized Official First Name:
JULIA
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER OF ENTITY
Authorized Official Telephone Number:
972-784-3064

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 141598673 . This is a "ORGANIZATIONAL NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 3866873 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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