1871850750 NPI number — GRAND PRAIRIE PROFESSIONAL GROUP, P. A.

Table of content: (NPI 1871850750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871850750 NPI number — GRAND PRAIRIE PROFESSIONAL GROUP, P. A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND PRAIRIE PROFESSIONAL GROUP, P. A.
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:
1871850750
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 POWELL PL
Provider Second Line Business Mailing Address:
ATTN: LEGAL DEPARTMENT
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-7514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-732-1605
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1171 107TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND PRAIRIE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75050-2502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-727-8387
Provider Business Practice Location Address Fax Number:
615-457-8094
Provider Enumeration Date:
04/18/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CALARCO
Authorized Official First Name:
MARK
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
FACILITY CEO
Authorized Official Telephone Number:
615-712-5862

Provider Taxonomy Codes

  • Taxonomy code: 2084P0802X , with the licence number:  E1948 , 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)





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