1649781931 NPI number — TOMMY L. POOL

Table of content: (NPI 1649781931)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649781931 NPI number — TOMMY L. POOL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOMMY L. POOL
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:
1649781931
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1205 W UNIVERSITY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79764-7119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-653-4981
Provider Business Mailing Address Fax Number:
877-614-6254

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1205 W UNIVERSITY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79764-7119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-653-4981
Provider Business Practice Location Address Fax Number:
877-614-6254
Provider Enumeration Date:
10/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
POOL
Authorized Official First Name:
TOMMY
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
432-653-4981

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 65821 . This is a "LICENSED PROFESSIONAL COUNSELOR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 10857 . This is a "LICENSED CHEMICAL DEPENDENCY COUNSELOR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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