1962467415 NPI number — FS TENANT POOL III TRUST

Table of content: (NPI 1962467415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962467415 NPI number — FS TENANT POOL III TRUST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FS TENANT POOL III TRUST
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:
HEALTHCARE CENTER AT THE FORUM AT PARK LANE
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:
1962467415
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7831 PARK LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75225-2000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-369-9902
Provider Business Mailing Address Fax Number:
214-373-1836

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7831 PARK LANE
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:
75225-2000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-369-9902
Provider Business Practice Location Address Fax Number:
214-373-1836
Provider Enumeration Date:
04/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POTTER
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
617-796-8387

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  110390 , 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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