1437134111 NPI number — LAKE WORTH INVESTMENTS INC.

Table of content: (NPI 1437134111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437134111 NPI number — LAKE WORTH INVESTMENTS INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE WORTH INVESTMENTS INC.
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:
1437134111
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4220 WELLS 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:
76135-2712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-237-6101
Provider Business Mailing Address Fax Number:
817-237-4864

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4220 WELLS DR
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:
76135-2712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-237-6101
Provider Business Practice Location Address Fax Number:
817-237-4864
Provider Enumeration Date:
12/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CASSTEVENS
Authorized Official First Name:
WILL
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
817-237-6101

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  110621 , 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: 001001122 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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