1225356363 NPI number — SBX TX OTB, PLLC

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 1225356363 NPI number — SBX TX OTB, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SBX TX OTB, PLLC
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:
1225356363
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1050
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-209-2295
Provider Business Mailing Address Fax Number:
859-236-5152

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 BELINDA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-209-2320
Provider Business Practice Location Address Fax Number:
859-209-4278
Provider Enumeration Date:
05/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DURHAM
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
HASTINGS
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
859-209-2305

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100151790 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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