1306372917 NPI number — LECELT, INC

Table of content: (NPI 1306372917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306372917 NPI number — LECELT, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LECELT, INC
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:
1306372917
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3371 KNICKERBOCKER RD
Provider Second Line Business Mailing Address:
# 236
Provider Business Mailing Address City Name:
SAN ANGELO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76904-6814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-703-6670
Provider Business Mailing Address Fax Number:
325-703-6672

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2133 OFFICE PARK DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANGELO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76904-6803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-703-6670
Provider Business Practice Location Address Fax Number:
325-703-6672
Provider Enumeration Date:
05/03/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HENRIKSON
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
325-703-6670

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , 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: 164744807 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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