1679270623 NPI number — HAVANA MEDICAL GROUP CORP

Table of content: (NPI 1679270623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679270623 NPI number — HAVANA MEDICAL GROUP CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAVANA MEDICAL GROUP CORP
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:
1679270623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
715 TELEPHONE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77023-3117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-871-4777
Provider Business Mailing Address Fax Number:
832-871-4776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 TELEPHONE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77023-3117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-871-4777
Provider Business Practice Location Address Fax Number:
832-871-4776
Provider Enumeration Date:
02/09/2023

Additional Information

Authorized Official

Authorized Official Last Name:
BASULTO BARCELAY
Authorized Official First Name:
NORBE
Authorized Official Middle Name:
LUIS
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
786-556-8819

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1861628505 . This is a "MOLINA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1861628505 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1861628505 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1861628505 . This is a "COMMUNITY HEALTH CHOICE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1861628505 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1861628505 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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