1821356734 NPI number — LIGHT JUNCTION PEDIATRICS HOME HEALTH LC

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 1821356734 NPI number — LIGHT JUNCTION PEDIATRICS HOME HEALTH LC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHT JUNCTION PEDIATRICS HOME HEALTH LC
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:
1821356734
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4858 TORTUGA TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WICHITA FALLS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76309-1228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-224-7200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
905 9TH ST
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
WICHITA FALLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76301-3423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-224-7200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PELSUE
Authorized Official First Name:
JOVITA
Authorized Official Middle Name:
LENORA
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
940-224-7200

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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