1528283280 NPI number — TCG BENBROOK AL, LLC

Table of content: (NPI 1528283280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528283280 NPI number — TCG BENBROOK AL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TCG BENBROOK AL, 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:
1528283280
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 SUMMIT AVE
Provider Second Line Business Mailing Address:
SUITE 444
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76102-4403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-446-4792
Provider Business Mailing Address Fax Number:
817-446-0923

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4242 BRYANT IRVIN RD
Provider Second Line Business Practice Location Address:
COVENANT PLACE OF BURLESON, LP
Provider Business Practice Location Address City Name:
BENBROOK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76109-4222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-763-0088
Provider Business Practice Location Address Fax Number:
817-763-8841
Provider Enumeration Date:
04/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCCALEB
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
817-446-4792

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  000619 , 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: 001014575 . This is a "CBA VENDOR NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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