1063749042 NPI number — 180 MEDICAL, INC.

Table of content: (NPI 1063749042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063749042 NPI number — 180 MEDICAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
180 MEDICAL, 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:
1063749042
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8516 NW EXPRESSWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73162-6010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-688-2729
Provider Business Mailing Address Fax Number:
888-718-0633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 N HEARNE AVE
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71107-7155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-798-4977
Provider Business Practice Location Address Fax Number:
888-718-0633
Provider Enumeration Date:
11/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HENDRIX
Authorized Official First Name:
JEFFERY
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
405-443-2985

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  DME.000354 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1016501 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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