1508992249 NPI number — PHOENIX HOUSES OF TEXAS, INC

Table of content: (NPI 1508992249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508992249 NPI number — PHOENIX HOUSES OF TEXAS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX HOUSES OF TEXAS, 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:
1508992249
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1910 PACIFIC AVE STE 10500
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:
75201-4591
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-920-1628
Provider Business Mailing Address Fax Number:
214-351-0967

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2345 REAGAN ST
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:
75219-3225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-999-1044
Provider Business Practice Location Address Fax Number:
214-526-3285
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LOEWEN
Authorized Official First Name:
BART
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
214-920-1628

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  865 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 170251601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 865-865M . This is a "STATE OF TEXAS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 865-865P . This is a "STATE OF TEXAS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 065459201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 319371601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 335999401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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