1316364193 NPI number — COLLOM AND CARNEY CLINIC ASSOCIATION

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 1316364193 NPI number — COLLOM AND CARNEY CLINIC ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLLOM AND CARNEY CLINIC ASSOCIATION
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:
1316364193
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5002 COWHORN CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75503-9766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-614-3000
Provider Business Mailing Address Fax Number:
903-614-3525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 W 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75501-4300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-614-3780
Provider Business Practice Location Address Fax Number:
903-614-3525
Provider Enumeration Date:
03/18/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DWIGHT
Authorized Official First Name:
MARY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
ASST ADMINISTRATOR OF PATIENT SERVI
Authorized Official Telephone Number:
903-614-3282

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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