1104137322 NPI number — POWELL PROFESSIONAL OF WEST TEXAS, LLC

Table of content: (NPI 1104137322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104137322 NPI number — POWELL PROFESSIONAL OF WEST TEXAS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POWELL PROFESSIONAL OF WEST TEXAS, LLC
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:
1104137322
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1239 BOWIE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78934-2343
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-733-0010
Provider Business Mailing Address Fax Number:
979-733-0051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROWNWOOD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76801-4430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-643-4840
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
POWELL
Authorized Official First Name:
RICKY
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
979-733-0010

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  100469 , 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: 100469 . This is a "TEXAS DEPARTMENT OF STATE HEALTH SERVICES" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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