1710276662 NPI number — EAST TEXAS FOOT AND ANKLE CENTERS, PA

Table of content: CRYSTAL EVELYN HENNINGS DPT (NPI 1609521152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710276662 NPI number — EAST TEXAS FOOT AND ANKLE CENTERS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS FOOT AND ANKLE CENTERS, PA
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:
1710276662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6603 OAK HILL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75703-0586
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-939-3668
Provider Business Mailing Address Fax Number:
903-939-0661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6603 OAK HILL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75703-0586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-939-3668
Provider Business Practice Location Address Fax Number:
903-939-0661
Provider Enumeration Date:
03/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KENT
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
903-939-3668

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  1927 , 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: 8CV514 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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