1356640254 NPI number — EAST TEXAS CLINICAL SERVICES, INC

Table of content: (NPI 1356640254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356640254 NPI number — EAST TEXAS CLINICAL SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS CLINICAL SERVICES, INC
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:
1356640254
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17521 ST. LUKE'S WAY
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
THE WOODLANDS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77384
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-447-9432
Provider Business Mailing Address Fax Number:
832-201-8622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17521 ST. LUKE'S WAY
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
THE WOODLANDS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77384
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-447-9432
Provider Business Practice Location Address Fax Number:
832-201-8622
Provider Enumeration Date:
03/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WEST
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
832-246-8066

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 31458 , 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)





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