1073991964 NPI number — HULLABALOO PEDIATRIC THERAPY PLLC

Table of content: (NPI 1073991964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073991964 NPI number — HULLABALOO PEDIATRIC THERAPY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HULLABALOO PEDIATRIC THERAPY 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:
1073991964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 GLENWOOD DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALESTINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-391-8170
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2035 CROCKETT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALESTINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75801-5921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-723-3602
Provider Business Practice Location Address Fax Number:
903-731-9573
Provider Enumeration Date:
05/11/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GRIMSLEY
Authorized Official First Name:
KRISTI
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
903-391-8170

Provider Taxonomy Codes

  • Taxonomy code: 261QH0700X , with the licence number:  108561 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X , with the licence number: 1099075 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0400X , with the licence number: 1099075 , 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: 108015203 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201775804 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 351507401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 351990201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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