1356341341 NPI number — TIM WASSON INCORPORATED

Table of content: (NPI 1356341341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356341341 NPI number — TIM WASSON INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIM WASSON INCORPORATED
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:
1356341341
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
612 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75652-2617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-657-1593
Provider Business Mailing Address Fax Number:
903-657-8448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
612 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75652-2617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-657-1593
Provider Business Practice Location Address Fax Number:
903-657-8448
Provider Enumeration Date:
07/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WASSON
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
TIM
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
903-657-1593

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  21419 , 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: 4567737 . This is a "NCPDP #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 143452 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com