1578805396 NPI number — MR. GARY DALE SACKETT II NP-C

Table of content: MR. GARY DALE SACKETT II NP-C (NPI 1578805396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578805396 NPI number — MR. GARY DALE SACKETT II NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SACKETT
Provider First Name:
GARY
Provider Middle Name:
DALE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
II
Provider Credential Text:
NP-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SACKETT
Provider Other First Name:
GARY
Provider Other Middle Name:
DALE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1578805396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1806 QUINCY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLAINVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79072-4206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-288-7891
Provider Business Mailing Address Fax Number:
806-288-7920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1806 QUINCY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLAINVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79072-4206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-288-7891
Provider Business Practice Location Address Fax Number:
806-288-7920
Provider Enumeration Date:
03/19/2013

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: 363LF0000X , with the licence number:  720249 , 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: 1578805396 . This is a "FAMILY MEDICINE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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