1396800389 NPI number — MSHC COLONIAL LODGE LLC

Table of content: DR. TERRY ALLEN WINTER D.D.S (NPI 1043376155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396800389 NPI number — MSHC COLONIAL LODGE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MSHC COLONIAL LODGE LLC
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:
1396800389
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 RICKETY LN
Provider Second Line Business Mailing Address:
STE 208
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75703-1702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-534-8667
Provider Business Mailing Address Fax Number:
903-509-0026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5001 ELIZABETH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-2913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-792-0838
Provider Business Practice Location Address Fax Number:
903-793-4562
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POWER
Authorized Official First Name:
CARLA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
903-534-8667

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  114502 , 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)

  • Identifier: 0010136550 . This is a "CBA CONTRACT" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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