1568996080 NPI number — HEAVENLY STALLIONS P.H.C., L.L.C

Table of content: (NPI 1568996080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568996080 NPI number — HEAVENLY STALLIONS P.H.C., L.L.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEAVENLY STALLIONS P.H.C., L.L.C
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:
1568996080
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 N WESTGATE DR STE 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESLACO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78599-4329
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-375-2009
Provider Business Mailing Address Fax Number:
956-375-2047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 N. WESTGATE DR.
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
WESLACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78599-7859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-375-2009
Provider Business Practice Location Address Fax Number:
956-375-2047
Provider Enumeration Date:
04/12/2017

Additional Information

Authorized Official

Authorized Official Last Name:
FLORES
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
956-460-2393

Provider Taxonomy Codes

  • Taxonomy code: 3747P1801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3764912-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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