1619026911 NPI number — LEONA STREET HOLDINGS I, LLC

Table of content: (NPI 1619026911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619026911 NPI number — LEONA STREET HOLDINGS I, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEONA STREET HOLDINGS I, LLC
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:
6
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:
1619026911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 E LEONA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UVALDE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78801-4740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-278-4880
Provider Business Mailing Address Fax Number:
830-278-4883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 E LEONA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UVALDE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78801-4740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-278-4880
Provider Business Practice Location Address Fax Number:
830-278-4883
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RAMIREZ
Authorized Official First Name:
ROGELIO
Authorized Official Middle Name:
ESQUIVEL
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
830-278-4880

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC6249 , 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: 00X864 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0089NP . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 192937401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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