1174509913 NPI number — MR. THEODORE ROOSEVELT HOUSTON

Table of content: MR. THEODORE ROOSEVELT HOUSTON (NPI 1174509913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174509913 NPI number — MR. THEODORE ROOSEVELT HOUSTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOUSTON
Provider First Name:
THEODORE
Provider Middle Name:
ROOSEVELT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1174509913
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2404 MEXIA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32304-1321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-576-4929
Provider Business Mailing Address Fax Number:
850-576-4929

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
855 W TENNESSEE ST
Provider Second Line Business Practice Location Address:
THAGARD HEALTH CENTER, FLORIDA STATE UNIVERSITY
Provider Business Practice Location Address City Name:
TALLAHASSEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32304-7834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-644-1015
Provider Business Practice Location Address Fax Number:
850-654-5570
Provider Enumeration Date:
12/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  12648 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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