1134452212 NPI number — BLUEGREEN INDUSTRIES LLC

Table of content: (NPI 1134452212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134452212 NPI number — BLUEGREEN INDUSTRIES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUEGREEN INDUSTRIES 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:
1134452212
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 765311
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75376-5311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-572-1500
Provider Business Mailing Address Fax Number:
972-572-1505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1666 N HAMPTON RD STE 100B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DESOTO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75115-8627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-572-1500
Provider Business Practice Location Address Fax Number:
972-572-1505
Provider Enumeration Date:
09/08/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
Authorized Official Title or Position:
PIC
Authorized Official Telephone Number:
972-572-1500

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 26621 , 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: 146063 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2121875 . This is a "PK" identifier . This identifiers is of the category "OTHER".