1205246220 NPI number — PEREGRINE VENTURES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205246220 NPI number — PEREGRINE VENTURES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEREGRINE VENTURES, 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:
1205246220
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4500 WILLIAMS DR
Provider Second Line Business Mailing Address:
STE 212-341
Provider Business Mailing Address City Name:
GEORGETOWN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78633-1332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-298-3901
Provider Business Mailing Address Fax Number:
512-298-3901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 SCENIC DR
Provider Second Line Business Practice Location Address:
SUITE 2222
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78626-7724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-298-3901
Provider Business Practice Location Address Fax Number:
512-298-3901
Provider Enumeration Date:
04/29/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SPINKS
Authorized Official First Name:
THEODORE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
512-298-3901

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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