1790328979 NPI number — MANALI HEALTHCARE PLLC

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 1790328979 NPI number — MANALI HEALTHCARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANALI HEALTHCARE 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:
1790328979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1014 HANOVER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHLAKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76092-8683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6913 CAMP BOWIE BLVD STE 171
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:
76116-7165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
682-558-4769
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/21/2019

Additional Information

Authorized Official

Authorized Official Last Name:
KALAKUNJA
Authorized Official First Name:
AROON
Authorized Official Middle Name:
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
682-558-4769

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1801857636 . This is a "NPI INDIVIDUAL" identifier . This identifiers is of the category "OTHER".




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