1093168049 NPI number — CHILDREN'S CLINIC OF JASPER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093168049 NPI number — CHILDREN'S CLINIC OF JASPER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDREN'S CLINIC OF JASPER
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:
1093168049
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 150638
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUFKIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75915-0638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-634-2214
Provider Business Mailing Address Fax Number:
936-639-9660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1008 DICKERSON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75951-5111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-634-2214
Provider Business Practice Location Address Fax Number:
936-639-9660
Provider Enumeration Date:
07/14/2016

Additional Information

Authorized Official

Authorized Official Last Name:
CROCKER
Authorized Official First Name:
CHERE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
936-634-2214

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  H4321 , 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: 191679301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 092130602 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com