1083732838 NPI number — ELDERPSYCH CARE PLLC

Table of content: (NPI 1083732838)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083732838 NPI number — ELDERPSYCH CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELDERPSYCH CARE 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:
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:
1083732838
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 938
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KILLEEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76540-0938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-634-6999
Provider Business Mailing Address Fax Number:
254-200-4099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1007 W. HIGHWAY 190
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
COPPERAS COVE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76522-3886
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-542-7200
Provider Business Practice Location Address Fax Number:
866-602-0977
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HUPP
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
254-542-7200

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 3-1593 , 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: 0087QA . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 188410801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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