1326236167 NPI number — DOUGLAS R CHEATHAM

Table of content: (NPI 1326236167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326236167 NPI number — DOUGLAS R CHEATHAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOUGLAS R CHEATHAM
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:
1326236167
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 190408
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75219-0408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-207-5664
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1626 W HIGHWAY 287 BUSINESS
Provider Second Line Business Practice Location Address:
SUITE #104
Provider Business Practice Location Address City Name:
WAXAHACHIE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75165-4712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-935-0027
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHEATHAM
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
RAY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
214-207-5664

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  11300 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 22513 , 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: 095323401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 098373601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 081432901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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