1083050694 NPI number — MANSFIELD WALNUT CREEK MEDICAL

Table of content: (NPI 1083050694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083050694 NPI number — MANSFIELD WALNUT CREEK MEDICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANSFIELD WALNUT CREEK MEDICAL
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:
1083050694
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 840795
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:
75284-0795
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-899-6666
Provider Business Mailing Address Fax Number:
972-899-5954

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
995 N WALNUT CREEK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76063-1503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-899-6666
Provider Business Practice Location Address Fax Number:
972-899-5954
Provider Enumeration Date:
05/22/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FIELDING
Authorized Official First Name:
TIM
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
972-899-6650

Provider Taxonomy Codes

  • Taxonomy code: 261QE0002X , with the licence number:  160085 , 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: 434148 . This is a "JACHO" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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