1912353905 NPI number — OLTON SURGICAL SERVICES, LLC

Table of content: (NPI 1912353905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912353905 NPI number — OLTON SURGICAL SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OLTON SURGICAL SERVICES, 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:
OLTON SURGICAL
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:
1912353905
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 541602
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77254-1602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-523-3066
Provider Business Mailing Address Fax Number:
832-602-2638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3375 WESTPARK DR
Provider Second Line Business Practice Location Address:
UNIT 442
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77005-4262
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-523-3066
Provider Business Practice Location Address Fax Number:
832-602-2638
Provider Enumeration Date:
05/09/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BRYANT
Authorized Official First Name:
KATHYANN
Authorized Official Middle Name:
CYNTHELESE
Authorized Official Title or Position:
LICENSED SURGICAL ASSISTANT
Authorized Official Telephone Number:
832-523-3066

Provider Taxonomy Codes

  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246ZC0007X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00P07U . This is a "BCBS - OLTON SURGICAL SERVICES, LLC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: SA00606 . This is a "SURGICAL ASSISTANT'S LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".