1538177621 NPI number — AVA LOUISE PORTERFIELD L.P.C.

Table of content: AVA LOUISE PORTERFIELD L.P.C. (NPI 1538177621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538177621 NPI number — AVA LOUISE PORTERFIELD L.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTERFIELD
Provider First Name:
AVA
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.P.C.
Provider Gender Code:
F

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:
1538177621
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 CHESTNUT STREET
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ABILENE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-676-8963
Provider Business Mailing Address Fax Number:
325-676-2915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 EAST 28TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRYAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77803-4029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-224-0832
Provider Business Practice Location Address Fax Number:
979-450-7896
Provider Enumeration Date:
08/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  14265 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101Y00000X , with the licence number: 14265 , 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: 84919L . This is a "BCBS OF TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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