1619047636 NPI number — BACK TO BACK MEDICAL EQUIPMENT DIST LLC

Table of content: (NPI 1619047636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619047636 NPI number — BACK TO BACK MEDICAL EQUIPMENT DIST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BACK TO BACK MEDICAL EQUIPMENT DIST LLC
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:
1619047636
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
817 SOUTHMORE AVE
Provider Second Line Business Mailing Address:
STE 100 I
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77502-1115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-477-0780
Provider Business Mailing Address Fax Number:
855-873-8930

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
817 SOUTHMORE AVE
Provider Second Line Business Practice Location Address:
STE 100 I
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77502-1115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-477-0780
Provider Business Practice Location Address Fax Number:
855-873-8930
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WASHINGTON
Authorized Official First Name:
ASHLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER CEO
Authorized Official Telephone Number:
713-477-0780

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  0075614 , 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: 10048516 . This is a "AMERIGROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1729295-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200436441 . This is a "PHCS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: HOMELINK . This is a "200436441" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 100265265301 . This is a "UNITEDHEALTH CARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8200381 . This is a "EVERCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 200436441 . This is a "INTEGRATED HEALTH PLAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 531679 . This is a "BLUECROSS/BLUESHIELD OF T" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1729295-02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 172929501 . This is a "COMM HEALTH CHOICE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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