1063415974 NPI number — CITY OF LA PORTE

Table of content: (NPI 1063415974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063415974 NPI number — CITY OF LA PORTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF LA PORTE
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:
1063415974
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 180446
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75218-0446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-602-2060
Provider Business Mailing Address Fax Number:
800-353-2196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10428 SPENCER HIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA PORTE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77571-6215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-470-0051
Provider Business Practice Location Address Fax Number:
800-353-2196
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KOMINEK
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
EMS CHIEF
Authorized Official Telephone Number:
281-470-0051

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  101077 , 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: 101077 . This is a "DSHS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1063415974 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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