1245406917 NPI number — CHOICE SOURCE LLC

Table of content: (NPI 1245406917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245406917 NPI number — CHOICE SOURCE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHOICE SOURCE 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:
CHOICE SOURCE THERAPEUTIC
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:
1245406917
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 ELM ST FL 5 LOCKBOX 840688
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75202-2910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-225-5967
Provider Business Mailing Address Fax Number:
909-799-4364

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 E COLLINS BLVD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
RICHARDSON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75081-2253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-992-3490
Provider Business Practice Location Address Fax Number:
972-619-8224
Provider Enumeration Date:
05/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BORDER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
AUTHORIZED SIGNATORY
Authorized Official Telephone Number:
800-225-5967

Provider Taxonomy Codes

  • Taxonomy code: 163WH0200X , with the licence number:  008085 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: 008085 , 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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