1588703185 NPI number — CHARLES MCKENZIE

Table of content: (NPI 1588703185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588703185 NPI number — CHARLES MCKENZIE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES MCKENZIE
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:
1588703185
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 OLEANDER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORPUS CHRISTI
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78404-1728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-851-0311
Provider Business Mailing Address Fax Number:
361-851-0990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4626 WEBER RD
Provider Second Line Business Practice Location Address:
SUITE 21
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78411-3543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-851-0311
Provider Business Practice Location Address Fax Number:
361-851-0311
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCKENZIE
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
361-851-0311

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , 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)





Copyright © 2007-2025 www.npivalidator.com