1487173357 NPI number — MANISHA DESAI

Table of content: JILL GEORJEAN GRANT ABA (NPI 1588354443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487173357 NPI number — MANISHA DESAI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANISHA DESAI
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:
1487173357
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 EAST 6TH STREET STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79761-6947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-580-0985
Provider Business Mailing Address Fax Number:
432-337-2666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 EAST 6TH STREET STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79761-6947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-580-0985
Provider Business Practice Location Address Fax Number:
432-337-2666
Provider Enumeration Date:
09/12/2017

Additional Information

Authorized Official

Authorized Official Last Name:
DESAI
Authorized Official First Name:
MANISHA
Authorized Official Middle Name:
MAHADEV
Authorized Official Title or Position:
ORGANIZATION OWNER/PROPRIETER
Authorized Official Telephone Number:
432-580-0985

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  K6561 , 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: 09226801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09226802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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