1639848724 NPI number — ADDISMIND PLLC

Table of content: (NPI 1639848724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639848724 NPI number — ADDISMIND PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADDISMIND PLLC
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:
1639848724
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4709 EXPOSITION WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76244-6094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-752-4613
Provider Business Mailing Address Fax Number:
917-382-2534

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1106 N STATE HIGHWAY 360 STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND PRAIRIE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75050-2511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-752-4613
Provider Business Practice Location Address Fax Number:
917-382-2534
Provider Enumeration Date:
09/10/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ARAYA
Authorized Official First Name:
HANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER OF ENTITY
Authorized Official Telephone Number:
817-752-4613

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)