1306898374 NPI number — TEXOMA KIDNEY CARE, P.A.

Table of content: (NPI 1306898374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306898374 NPI number — TEXOMA KIDNEY CARE, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEXOMA KIDNEY CARE, P.A.
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:
1306898374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 MEMORIAL DR
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
DENISON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75020-2026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-463-5057
Provider Business Mailing Address Fax Number:
903-463-7661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 MEMORIAL DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
DENISON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75020-2026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-463-5057
Provider Business Practice Location Address Fax Number:
903-463-7661
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIE
Authorized Official First Name:
GLEN
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
903-463-5057

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G0858 , 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: DF3764 . This is a "OK RAILROAD MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 0031EE . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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