1326061235 NPI number — LEASA L ROACH GNP

Table of content: LEASA L ROACH GNP (NPI 1326061235)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326061235 NPI number — LEASA L ROACH GNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROACH
Provider First Name:
LEASA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
GNP
Provider Gender Code:
F

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:
1326061235
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1205 E 35TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71854-2746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-835-5355
Provider Business Mailing Address Fax Number:
903-735-5399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1205 E 35TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71854-2746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-735-5355
Provider Business Practice Location Address Fax Number:
903-735-5399
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LG0600X , with the licence number:  526631 , 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: 526631 . This is a "LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 163821758 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8Y1726 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5A158 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: P00376988 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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