1275994550 NPI number — HIDDEN JEWEL HEALTHCARE RESOURE SERVICE

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 1275994550 NPI number — HIDDEN JEWEL HEALTHCARE RESOURE SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIDDEN JEWEL HEALTHCARE RESOURE SERVICE
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:
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:
1275994550
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 398370
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:
75339-8370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-789-9205
Provider Business Mailing Address Fax Number:
972-224-0411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1305 KENTUCKY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75134-1688
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-789-9205
Provider Business Practice Location Address Fax Number:
972-224-0411
Provider Enumeration Date:
03/14/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
469-789-9205

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , 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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