1902079437 NPI number — COUNTRY PATHWAYS PLLC

Table of content: (NPI 1902079437)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902079437 NPI number — COUNTRY PATHWAYS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRY PATHWAYS 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:
COUNTRY PATHWAYS PLLC
Provider Other Organization Name Type Code:
3
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:
1902079437
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1804 LIVINGSTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75601-3724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-850-6334
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 WAIN DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75604-1231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-850-6334
Provider Business Practice Location Address Fax Number:
903-236-8510
Provider Enumeration Date:
04/04/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHELETTE WILSON
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
903-365-2198

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  15127 , 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: 028036401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".