1154089548 NPI number — BCW GROUP LLC

Table of content: (NPI 1154089548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154089548 NPI number — BCW GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BCW GROUP 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:
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:
1154089548
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
803 GALLAGHER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHERMAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75090-1750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-747-1644
Provider Business Mailing Address Fax Number:
903-408-6441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
803 GALLAGHER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHERMAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75090-1750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-747-1644
Provider Business Practice Location Address Fax Number:
903-408-6441
Provider Enumeration Date:
12/02/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CESSNUN
Authorized Official First Name:
SHANE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
580-380-4462

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4116196 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200866750A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".