1972581882 NPI number — HEARTWAY III CORPORATION

Table of content: (NPI 1972581882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972581882 NPI number — HEARTWAY III CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEARTWAY III CORPORATION
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:
AVALON PLACE-WHARTON
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:
1972581882
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1405 VALHALLA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHARTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77488-9218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-532-1244
Provider Business Mailing Address Fax Number:
979-532-1142

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1405 VALHALLA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHARTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77488-9218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-532-1244
Provider Business Practice Location Address Fax Number:
979-532-1142
Provider Enumeration Date:
01/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OBERGFELL
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
PRESIDENT, BOARD OF DIRECTORS
Authorized Official Telephone Number:
214-777-0282

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  112200 , 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)