1528283306 NPI number — HEALTH TEXAS PROVIDER NETWORK

Table of content: (NPI 1528283306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528283306 NPI number — HEALTH TEXAS PROVIDER NETWORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTH TEXAS PROVIDER NETWORK
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:
PCA-LEONARD
Provider Other Organization Name Type Code:
3
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:
1528283306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 844128
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:
75284-4128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-800-3524
Provider Business Mailing Address Fax Number:
469-800-3564

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 N STATE HIGHWAY 78
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEONARD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75452-0198
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-587-3331
Provider Business Practice Location Address Fax Number:
903-587-2395
Provider Enumeration Date:
04/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CANTRELL
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
903-587-3331

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 006EE . This is a "BCBS GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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