1013934751 NPI number — ST NICHOLAS PROVIDER SERVICES INC

Table of content: (NPI 1013934751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013934751 NPI number — ST NICHOLAS PROVIDER SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST NICHOLAS PROVIDER SERVICES INC
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:
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:
1013934751
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7008 LAKE JACKSON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76002-4054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-468-9006
Provider Business Mailing Address Fax Number:
817-468-9006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7008 LAKE JACKSON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76002-4054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-468-9006
Provider Business Practice Location Address Fax Number:
817-468-9006
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FASAKIN
Authorized Official First Name:
OLUFESOLA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
817-468-9006

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  010407 , 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: 010407 . This is a "STATE HOME HEALTH LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 205352201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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