1639367329 NPI number — TCSD CLINIC LLC

Table of content: (NPI 1639367329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639367329 NPI number — TCSD CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TCSD CLINIC 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:
1639367329
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5576
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMOND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73083-5576
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-285-4914
Provider Business Mailing Address Fax Number:
405-285-7127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3120 W SOUTHLAKE BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SOUTHLAKE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76092-6783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-741-4521
Provider Business Practice Location Address Fax Number:
817-741-4279
Provider Enumeration Date:
10/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WALL
Authorized Official First Name:
SHELLI
Authorized Official Middle Name:
M
Authorized Official Title or Position:
INSURANCE CONTRACTING SPECIALIST
Authorized Official Telephone Number:
405-285-4914

Provider Taxonomy Codes

  • Taxonomy code: 261QS1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com