1902425093 NPI number — BLUE STAR REHABILITATION PLANO LLC

Table of content: (NPI 1902425093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902425093 NPI number — BLUE STAR REHABILITATION PLANO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE STAR REHABILITATION PLANO 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:
BLUE STAR FAMILY MEDICINE
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:
1902425093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 W AIRPORT FWY # 959
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75062-6312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-445-4134
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17754 PRESTON RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75252-5638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-476-9036
Provider Business Practice Location Address Fax Number:
972-476-9926
Provider Enumeration Date:
04/09/2020

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
972-445-4134

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1588051114 . This is a "ADDITIONAL ORGANIZATION NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com