1366781676 NPI number — MRS. MARY L HALLIBURTON RDN,CSR, LD

Table of content: MRS. MARY L HALLIBURTON RDN,CSR, LD (NPI 1366781676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366781676 NPI number — MRS. MARY L HALLIBURTON RDN,CSR, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALLIBURTON
Provider First Name:
MARY
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RDN,CSR, LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1366781676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4741 JOEL DR APT 33
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79924-6968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-490-1718
Provider Business Mailing Address Fax Number:
915-307-8678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4741 JOEL DRIVE
Provider Second Line Business Practice Location Address:
APT 33
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-490-1718
Provider Business Practice Location Address Fax Number:
915-307-8678
Provider Enumeration Date:
02/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133VN1005X , with the licence number:  DT81903 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 133VN1006X , with the licence number: DT81903 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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