1457614612 NPI number — J & T PARK ENTERPRISES, LTD.

Table of content: (NPI 1457614612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457614612 NPI number — J & T PARK ENTERPRISES, LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J & T PARK ENTERPRISES, LTD.
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:
1457614612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
788 COOKS CORNER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POTTSBORO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75076-6042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-341-8883
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
788 COOKS CORNER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POTTSBORO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75076-6042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-341-8883
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PARK
Authorized Official First Name:
VICTORIA
Authorized Official Middle Name:
CUCCIA
Authorized Official Title or Position:
REGISTERED DIETITIAN
Authorized Official Telephone Number:
806-341-8883

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  DT04601 , 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: 1356573166 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: TXB154636 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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