1699822981 NPI number — SOUTHPOINTE FAMILY RESOURCE CENTER, P.C.

Table of content: (NPI 1699822981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699822981 NPI number — SOUTHPOINTE FAMILY RESOURCE CENTER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHPOINTE FAMILY RESOURCE CENTER, P.C.
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:
1699822981
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
435 SHORT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DACONO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80514-5040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-432-3629
Provider Business Mailing Address Fax Number:
303-200-7218

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4710 TABLE MESA DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80305-4504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-432-3629
Provider Business Practice Location Address Fax Number:
303-200-7218
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHARER-MOHATT
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
402-432-3629

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  445 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1114002102 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 27350 . This is a "PTAN" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 098990 . This is a "PTAN" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 1982293734 . This is a "NPI" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 1699822971 . This is a "GROUP NPI" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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