1639245764 NPI number — DEPARTMENT OF STATE HEALTH SERVICES

Table of content: (NPI 1639245764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639245764 NPI number — DEPARTMENT OF STATE HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEPARTMENT OF STATE HEALTH SERVICES
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:
1639245764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 W 49TH ST
Provider Second Line Business Mailing Address:
HSR 7 - TEMPLE
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78756-3101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-458-7111
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2408 S 37TH ST
Provider Second Line Business Practice Location Address:
ATTN BILLING OFFICE
Provider Business Practice Location Address City Name:
TEMPLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76504-7168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-778-6744
Provider Business Practice Location Address Fax Number:
254-778-6819
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BETZ
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
DEPUTY REGIONAL DIRECTOR
Authorized Official Telephone Number:
254-778-6744

Provider Taxonomy Codes

  • Taxonomy code: 261QP0905X , 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: 136129704 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 136368105 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 136480406 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 138359802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 136130503 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 138359803 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 133560605 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 135248605 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 134758503 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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