1487621306 NPI number — LISE AMY LABICHE

Table of content: LISE AMY LABICHE (NPI 1487621306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487621306 NPI number — LISE AMY LABICHE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LABICHE
Provider First Name:
LISE
Provider Middle Name:
AMY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LABICHE
Provider Other First Name:
LISE
Provider Other Middle Name:
AMY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1487621306
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 678186
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:
75267-8186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-306-7783
Provider Business Mailing Address Fax Number:
303-306-7753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3535 S INTERSTATE 35 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76210-6850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-384-3535
Provider Business Practice Location Address Fax Number:
303-306-7753
Provider Enumeration Date:
03/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  2356 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 036-162508 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: K9830 , 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: 158290002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00477936 . This is a "RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: K9830 . This is a "TEXAS MEDICAL LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 105395500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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