1295795755 NPI number — BRIAN GAMBORG

Table of content: BRIAN GAMBORG (NPI 1295795755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295795755 NPI number — BRIAN GAMBORG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAMBORG
Provider First Name:
BRIAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1295795755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 123453 DEPT 3453
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:
75312-3453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-494-2921
Provider Business Mailing Address Fax Number:
337-494-6523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1525 OAK PARK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CHARLES
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70601-8849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-494-6767
Provider Business Practice Location Address Fax Number:
337-494-6750
Provider Enumeration Date:
03/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  023359 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1694878 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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