1154312148 NPI number — JERRY IKE

Table of content: (NPI 1154312148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154312148 NPI number — JERRY IKE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JERRY IKE
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:
1154312148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2306 OAK LN., STE 16
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND PRAIRIE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-262-7752
Provider Business Mailing Address Fax Number:
972-237-0430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2306 OAK LN.
Provider Second Line Business Practice Location Address:
STE 16
Provider Business Practice Location Address City Name:
GRAND PRAIRIE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-262-7752
Provider Business Practice Location Address Fax Number:
972-237-0430
Provider Enumeration Date:
10/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
IKE
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
972-262-7752

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  0071940 , 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: TPI 170054401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: TPI 170054402 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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