1508992249 NPI number — PHOENIX HOUSES OF TEXAS, INC

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 1508992249 NPI number — PHOENIX HOUSES OF TEXAS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX HOUSES OF TEXAS, INC
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:
1508992249
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1910 PACIFIC AVE STE 10500
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:
75201-4591
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-920-1628
Provider Business Mailing Address Fax Number:
214-351-0967

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2345 REAGAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75219-3225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-999-1044
Provider Business Practice Location Address Fax Number:
214-526-3285
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LOEWEN
Authorized Official First Name:
BART
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
214-920-1628

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X , with the licence number: 865 , 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: 170251601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 865-865M . This is a "STATE OF TEXAS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 865-865P . This is a "STATE OF TEXAS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 065459201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 319371601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 335999401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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