1316243728 NPI number — PROVIDACARE MEDICAL SUPPLY, LTD.

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 1316243728 NPI number — PROVIDACARE MEDICAL SUPPLY, LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDACARE MEDICAL SUPPLY, LTD.
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:
1316243728
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3721 EXECUTIVE CENTER DRIVE
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78731-1615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-733-6518
Provider Business Mailing Address Fax Number:
512-795-9185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1514 S 31ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76504-6752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-778-2727
Provider Business Practice Location Address Fax Number:
254-778-2729
Provider Enumeration Date:
02/02/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
512-733-6518

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  1000495 , 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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