1346796604 NPI number — HEALTHCARE STAT OF NEWCASTLE LLC

Table of content: (NPI 1346796604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346796604 NPI number — HEALTHCARE STAT OF NEWCASTLE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHCARE STAT OF NEWCASTLE LLC
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:
1346796604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5908
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORMAN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73070-5908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-659-5656
Provider Business Mailing Address Fax Number:
405-701-5421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2120 N MAIN ST SUITE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWCASTLE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-792-0200
Provider Business Practice Location Address Fax Number:
405-701-5421
Provider Enumeration Date:
08/28/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BONILLA
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
405-792-0200

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  68442 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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