1639441751 NPI number — TEXAS HEALTH CARE PLLC

Table of content: (NPI 1639441751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639441751 NPI number — TEXAS HEALTH CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEXAS HEALTH CARE PLLC
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:
1639441751
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 961205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76161-1205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-740-8400
Provider Business Mailing Address Fax Number:
817-378-3699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 8TH AVENUE, SUITE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-4158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-335-8151
Provider Business Practice Location Address Fax Number:
817-926-2531
Provider Enumeration Date:
02/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
TATUM
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
C.E.O.
Authorized Official Telephone Number:
817-740-8400

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 155109501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com