1275765695 NPI number — BETHANY HH OF CLEAR LAKE, LLC

Table of content: (NPI 1275765695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275765695 NPI number — BETHANY HH OF CLEAR LAKE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BETHANY HH OF CLEAR LAKE, 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:
1275765695
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 LEGACY DR
Provider Second Line Business Mailing Address:
SUITE 360
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75024-3100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-248-2441
Provider Business Mailing Address Fax Number:
972-248-0773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 NASA PKWY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77058-3325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-984-7670
Provider Business Practice Location Address Fax Number:
832-224-4315
Provider Enumeration Date:
08/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LASSITER
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
972-248-2441

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2958845-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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