1730636325 NPI number — THE DRAW STATION LLC

Table of content: (NPI 1730636325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730636325 NPI number — THE DRAW STATION LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE DRAW STATION 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:
1730636325
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1452
Provider Second Line Business Mailing Address:
18407 JOHNNY B HALL MEM HWY
Provider Business Mailing Address City Name:
ROSEPINE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70659
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-463-7535
Provider Business Mailing Address Fax Number:
337-202-1897

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18407 JOHNNY B HALL MEM HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEPINE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-463-7535
Provider Business Practice Location Address Fax Number:
337-202-1897
Provider Enumeration Date:
09/01/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PRIMEAUX
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
337-463-7535

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  CLP.G0073-GEN , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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