1386309276 NPI number — MEDICAL FITNESS CLINIC OF KERRVILLE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386309276 NPI number — MEDICAL FITNESS CLINIC OF KERRVILLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL FITNESS CLINIC OF KERRVILLE
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:
1386309276
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1007 RIVER TRAIL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PIPE CREEK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78063-5979
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-569-4129
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1337 BANDERA HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERRVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78028-9555
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-569-4129
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/04/2021

Additional Information

Authorized Official

Authorized Official Last Name:
BLACK
Authorized Official First Name:
BYRON
Authorized Official Middle Name:
KEITH
Authorized Official Title or Position:
MANAGER/OWNER
Authorized Official Telephone Number:
210-569-4129

Provider Taxonomy Codes

  • Taxonomy code: 224Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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