1366777625 NPI number — NTKC-DFW, PLLC

Table of content: (NPI 1366777625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366777625 NPI number — NTKC-DFW, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NTKC-DFW, PLLC
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:
1366777625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3801 WILLIAM D TATE AVE STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAPEVINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76051-8755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-488-6812
Provider Business Mailing Address Fax Number:
817-251-1303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
805 HILL BLVD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
GRANBURY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76048-1481
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-294-0280
Provider Business Practice Location Address Fax Number:
817-294-2084
Provider Enumeration Date:
10/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BACCUS
Authorized Official First Name:
DAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
817-488-6669

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 208809801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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