1659633873 NPI number — SAN ANTONIO MEDICAL SUPPLIES LLC

Table of content: (NPI 1659633873)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659633873 NPI number — SAN ANTONIO MEDICAL SUPPLIES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN ANTONIO MEDICAL SUPPLIES 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:
1659633873
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 100456
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78201-1756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-737-7267
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 NE LOOP 410
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78217-5213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-737-7267
Provider Business Practice Location Address Fax Number:
210-737-7262
Provider Enumeration Date:
06/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ZUFLACHT-CUKJATI
Authorized Official First Name:
ANDREA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
M.S. - LPC-S
Authorized Official Telephone Number:
210-737-7267

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  1000945 , 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: 308842902 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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