1053670612 NPI number — LAVENDER AND LACE BIRTH & WOMENS HEALTH SERVICES PLLC

Table of content: (NPI 1053670612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053670612 NPI number — LAVENDER AND LACE BIRTH & WOMENS HEALTH SERVICES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAVENDER AND LACE BIRTH & WOMENS HEALTH SERVICES PLLC
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:
1053670612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1204 GARNER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NACOGDOCHES
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75961-4278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-789-8258
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 JACOB STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIMPSON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75975-5028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-254-3338
Provider Business Practice Location Address Fax Number:
936-254-3339
Provider Enumeration Date:
05/16/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
MARCIA
Authorized Official Middle Name:
DEE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
409-789-8258

Provider Taxonomy Codes

  • Taxonomy code: 176B00000X , with the licence number:  251633 , 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: 307575601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1053670612 . This is a "TYPE II NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".