1306106687 NPI number — JACQUELENE MITCHELL ADIELE, MD, PA

Table of content: (NPI 1306106687)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306106687 NPI number — JACQUELENE MITCHELL ADIELE, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACQUELENE MITCHELL ADIELE, MD, PA
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:
1306106687
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 938
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KILLEEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76540-0938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-634-6999
Provider Business Mailing Address Fax Number:
254-200-4099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3816 S CLEAR CREEK RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
KILLEEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76549-4400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-200-2748
Provider Business Practice Location Address Fax Number:
254-200-2757
Provider Enumeration Date:
05/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ADIELE
Authorized Official First Name:
JACQUELENE
Authorized Official Middle Name:
MITCHELL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
254-371-1172

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  J2678 , 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)

  • Identifier: 1609896497 . This is a "NPI (INDIVIDUAL)" identifier . This identifiers is of the category "OTHER".
  • Identifier: 034049902 . This is a "MEDICAID (INDIVIDUAL)" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 306297801 . This is a "MEDICAID (GROUP)" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TXB158052 . This is a "MEDICARE (GROUP)" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1306106687 . This is a "NPI (GROUP)" identifier . This identifiers is of the category "OTHER".
  • Identifier: TXB158053 . This is a "MEDICARE (INDIVIDUAL)" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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