1699902023 NPI number — MRS. THERESA LORENE ANDERSON RDH

Table of content: MRS. THERESA LORENE ANDERSON RDH (NPI 1699902023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699902023 NPI number — MRS. THERESA LORENE ANDERSON RDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
THERESA
Provider Middle Name:
LORENE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RDH
Provider Gender Code:
F

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:
1699902023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4905 PALOMINO LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75043-3518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-240-3014
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1927 FAITHON P LUCAS SR BLVD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
MESQUITE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75181-1696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-341-3888
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X , with the licence number:  13282 , 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)





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