1558834614 NPI number — CHILDREN'S CLINIC OF CROCKETT

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 1558834614 NPI number — CHILDREN'S CLINIC OF CROCKETT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDREN'S CLINIC OF CROCKETT
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:
1558834614
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 150638
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUFKIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75915-0638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-634-2214
Provider Business Mailing Address Fax Number:
936-634-2301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
951 E LOOP 304
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROCKETT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75835-5403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-634-2214
Provider Business Practice Location Address Fax Number:
936-634-2301
Provider Enumeration Date:
01/10/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GLASS
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
936-634-2214

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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