1689026676 NPI number — KNEE COASTER, LLC

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 1689026676 NPI number — KNEE COASTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KNEE COASTER, 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:
1689026676
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
835 E LAMAR BLVD
Provider Second Line Business Mailing Address:
STE 388
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-798-7817
Provider Business Mailing Address Fax Number:
844-734-2233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1675 SOTOGRANDE BLVD
Provider Second Line Business Practice Location Address:
202
Provider Business Practice Location Address City Name:
HURST
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-798-7817
Provider Business Practice Location Address Fax Number:
844-734-2233
Provider Enumeration Date:
07/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
COBB
Authorized Official First Name:
EMILY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
817-798-7817

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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