1508085143 NPI number — PREVENTIVE MEDICINE CLINIC OF DALLAS

Table of content: MR. LEO RAPHAEL BLATZ R.N. (NPI 1427758242)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508085143 NPI number — PREVENTIVE MEDICINE CLINIC OF DALLAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREVENTIVE MEDICINE CLINIC OF DALLAS
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:
1508085143
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2445 W NORTHWEST HWY STE 105
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:
75220-4448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-352-9600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2445 W NORTHWEST HWY STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75220-4448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-352-9600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SALINAS
Authorized Official First Name:
HERIBERTO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
214-352-9600

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 098964201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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