1457800245 NPI number — WALK IN FAITH, PHC, LLC

Table of content: (NPI 1457800245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457800245 NPI number — WALK IN FAITH, PHC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALK IN FAITH, PHC, 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:
6
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:
1457800245
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 GIL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN BENITO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78586-4109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-626-1422
Provider Business Mailing Address Fax Number:
844-315-7635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 GIL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN BENITO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78586-4109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-626-1422
Provider Business Practice Location Address Fax Number:
844-315-7635
Provider Enumeration Date:
09/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
RODRIGUEZ
Authorized Official First Name:
JOSIE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
956-241-1503

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3747P1801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0802517983 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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