1689868861 NPI number — SUBTENANT 3611 DICKASON AVENUE, LLC

Table of content: (NPI 1689868861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689868861 NPI number — SUBTENANT 3611 DICKASON AVENUE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUBTENANT 3611 DICKASON AVENUE, 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:
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:
1689868861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3611 DICKASON AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75219-4912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-559-0140
Provider Business Mailing Address Fax Number:
214-559-0171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3611 DICKASON AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75219-4912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-559-0140
Provider Business Practice Location Address Fax Number:
214-559-0171
Provider Enumeration Date:
08/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OBORN
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
C
Authorized Official Title or Position:
REGIONAL VP OF OPERATIONS
Authorized Official Telephone Number:
949-240-7200

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 130513 , 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: 001019490 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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