1427285204 NPI number — MRS. THERESA MARY PESCATELLO RDH

Table of content: MRS. THERESA MARY PESCATELLO RDH (NPI 1427285204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427285204 NPI number — MRS. THERESA MARY PESCATELLO RDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PESCATELLO
Provider First Name:
THERESA
Provider Middle Name:
MARY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RDH
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:
1427285204
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7401 JANETTA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76180-6744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-240-9368
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6729 BRIDGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76112-0817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-654-0354
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/18/2009

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: 124Q00000X , with the licence number:  15033 , 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)





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