1972731495 NPI number — BALCONES HEALTHCARE ASSOCIATES, PA

Table of content: (NPI 1972731495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972731495 NPI number — BALCONES HEALTHCARE ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALCONES HEALTHCARE ASSOCIATES, PA
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:
Provider Other Organization Name Type Code:
6
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:
1972731495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 268969
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73126-8969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-868-4352
Provider Business Mailing Address Fax Number:
512-868-4354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 COUNTY ROAD 340A
Provider Second Line Business Practice Location Address:
BUILDING 1, SUITE 4
Provider Business Practice Location Address City Name:
BURNET
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78611-4537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-868-4352
Provider Business Practice Location Address Fax Number:
512-868-4354
Provider Enumeration Date:
06/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BURGEST
Authorized Official First Name:
SEAN
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
512-868-4352

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X , with the licence number:  L9637 , 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: 2128704-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com