1588770820 NPI number — CHOICE MEDICAL SUPPLY INC

Table of content: (NPI 1588770820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588770820 NPI number — CHOICE MEDICAL SUPPLY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHOICE MEDICAL SUPPLY INC
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:
1588770820
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 WINDMILL CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABILENE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79606-5234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-677-2250
Provider Business Mailing Address Fax Number:
325-677-2124

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1705 HWY 1431
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARBLE FALLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78654-4921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-798-9248
Provider Business Practice Location Address Fax Number:
830-798-9249
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ADAMS
Authorized Official First Name:
J'LYNN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
325-677-2250

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  14059 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 0065657 , 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: 519707 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 10013733 . This is a "AMERIGROUP MEDICAID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 112361 . This is a "SUPERIOR MEDICAID NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 157888202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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