1003295429 NPI number — CHUDLEIGH, PA

Table of content: (NPI 1003295429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003295429 NPI number — CHUDLEIGH, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHUDLEIGH, 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:
1003295429
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3724 EXECUTIVE CENTER DR
Provider Second Line Business Mailing Address:
STE 230
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78731-1646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-452-2100
Provider Business Mailing Address Fax Number:
855-456-7410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3724 EXECUTIVE CENTER DR
Provider Second Line Business Practice Location Address:
STE 230
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78731-1646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-452-2100
Provider Business Practice Location Address Fax Number:
855-456-7410
Provider Enumeration Date:
05/19/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CHUDLEIGH
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
512-452-2100

Provider Taxonomy Codes

  • Taxonomy code: 364SG0600X , with the licence number:  F1450 , 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: 00651Y . This is a "PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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