1124057948 NPI number — CITY OF KEENE TEX

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 1124057948 NPI number — CITY OF KEENE TEX

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF KEENE TEX
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:
1124057948
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 N MOCKINGBIRD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEENE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76059-2323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-556-2474
Provider Business Mailing Address Fax Number:
817-645-8080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 W HILLCREST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEENE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-648-7536
Provider Business Practice Location Address Fax Number:
817-645-8080
Provider Enumeration Date:
07/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BEESON
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
972-339-4234

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  300110 , 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: 088197101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com