1013208776 NPI number — SOY INTY PA

Table of content: (NPI 1013208776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013208776 NPI number — SOY INTY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOY INTY 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:
1013208776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9201 DYER ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79924-6441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-751-7070
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9201 DYER ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79924-6441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-751-7070
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BAILEY
Authorized Official First Name:
DWIGHT
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
915-751-7070

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  24393 , 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: 1538314232 . This is a "NPI TYPE 1" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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