1104093913 NPI number — DIVYATISH PRIMARY CARE HEALTH SERVICES

Table of content: JOBETH RAE LOREMAN LMT (NPI 1174234413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104093913 NPI number — DIVYATISH PRIMARY CARE HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVYATISH PRIMARY CARE HEALTH SERVICES
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:
1104093913
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3685
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VICTORIA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77903-3685
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-576-3680
Provider Business Mailing Address Fax Number:
361-576-4219

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 E SAN ANTONIO ST STE 304W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICTORIA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77901-6040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-576-3680
Provider Business Practice Location Address Fax Number:
361-576-4219
Provider Enumeration Date:
05/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JAIN
Authorized Official First Name:
ARUN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
361-576-3680

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  L8086 , 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)





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