1124043039 NPI number — PRAC HOLDINGS, INC.

Table of content: (NPI 1124043039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124043039 NPI number — PRAC HOLDINGS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRAC HOLDINGS, INC.
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:
1124043039
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2300 WARRENVILLE RD., STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOWNERS GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60515-1765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-3530
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4615 N 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85718-5608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-888-7566
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DARBY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP NATIONAL CONTRACTS
Authorized Official Telephone Number:
630-296-3443

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  HHA1269 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 961872 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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