1487705067 NPI number — TRI-COUNTY GROUP XV, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487705067 NPI number — TRI-COUNTY GROUP XV, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-COUNTY GROUP XV, 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:
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:
1487705067
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3010 LYNDON B JOHNSON FWY STE 1100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75234-2712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-768-4373
Provider Business Mailing Address Fax Number:
903-537-8420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2016 N WESTWOOD BLVD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POPLAR BLUFF
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63901-2810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-824-1505
Provider Business Practice Location Address Fax Number:
573-776-6050
Provider Enumeration Date:
01/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MONASTIERE
Authorized Official First Name:
KATIE
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
COMPLIANCE PRIVACY & SAFETY OFFICER
Authorized Official Telephone Number:
517-768-4373

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 281701706 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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