1366879314 NPI number — CROSS MEDICAL CLINIC PLLC

Table of content: (NPI 1366879314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366879314 NPI number — CROSS MEDICAL CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROSS MEDICAL CLINIC 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:
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:
1366879314
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1614
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANYON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79015-1614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-557-4138
Provider Business Mailing Address Fax Number:
806-557-4165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1619 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANYON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79015-3824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-418-5880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FULLER
Authorized Official First Name:
GLORIA
Authorized Official Middle Name:
RODRIGUEZ
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
806-418-5880

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  694365 , 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)





Copyright © 2007-2025 www.npivalidator.com