1174724710 NPI number — VILLA QUILT OF CORPUS SOUTH, LP

Table of content: MISS RACHEL ELLEN LEETH INDEPENDENT PROVIDER (NPI 1891905204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174724710 NPI number — VILLA QUILT OF CORPUS SOUTH, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VILLA QUILT OF CORPUS SOUTH, LP
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:
VILLA OF CORPUS CHRISTI SOUTH
Provider Other Organization Name Type Code:
3
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:
1174724710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4834 YORKTOWN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORPUS CHRISTI
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78413-5364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-991-3252
Provider Business Mailing Address Fax Number:
361-242-9764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4834 YORKTOWN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78413-5364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-991-3252
Provider Business Practice Location Address Fax Number:
361-242-9764
Provider Enumeration Date:
05/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WITT
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
505-797-8735

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  000317 , 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)





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