1679883755 NPI number — TEXOMA ALLERGY GROUP, PLLC

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 1679883755 NPI number — TEXOMA ALLERGY GROUP, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEXOMA ALLERGY GROUP, 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:
SOUTHWEST ALLERGY& ASTHMA CENTER
Provider Other Organization Name Type Code:
3
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:
1679883755
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6101 WINDCOM COURT
Provider Second Line Business Mailing Address:
STE 400
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75093-7817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-398-3500
Provider Business Mailing Address Fax Number:
972-398-3512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5012 SOUTH US HIGHWAY 75
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
DENISON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-398-3500
Provider Business Practice Location Address Fax Number:
972-398-3572
Provider Enumeration Date:
10/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
VAN WAGONER
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
A,
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
972-398-3500

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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