1457483299 NPI number — LONGBOARD SURGICAL ASSOCIATES, PA

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 1457483299 NPI number — LONGBOARD SURGICAL ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONGBOARD SURGICAL ASSOCIATES, PA
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:
1457483299
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 122141
Provider Second Line Business Mailing Address:
DEPT 2141
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75312-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-355-8600
Provider Business Mailing Address Fax Number:
713-355-8069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4120 SOUTHWEST FWY
Provider Second Line Business Practice Location Address:
200
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77027-7339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-355-8600
Provider Business Practice Location Address Fax Number:
713-355-8069
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ELLIS
Authorized Official First Name:
JODIE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
BUSINESS OFFICE COORDINATOR
Authorized Official Telephone Number:
713-355-8600

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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