1669545067 NPI number — GOLDEN TRIANGLE FAMILY CARE CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669545067 NPI number — GOLDEN TRIANGLE FAMILY CARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLDEN TRIANGLE FAMILY CARE CENTER
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:
1669545067
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 W ROUND BUNCH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIDGE CITY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77611-2434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-735-7305
Provider Business Mailing Address Fax Number:
409-792-0201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 W ROUND BUNCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGE CITY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77611-2434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-735-7305
Provider Business Practice Location Address Fax Number:
888-972-9401
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PENNING
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
409-735-7305

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 159305501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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