1720220304 NPI number — JORDAN J MASWOSWE

Table of content: (NPI 1720220304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720220304 NPI number — JORDAN J MASWOSWE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JORDAN J MASWOSWE
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:
1720220304
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11556
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77391-1556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-446-6826
Provider Business Mailing Address Fax Number:
832-553-7400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6402 LOUETTA RD
Provider Second Line Business Practice Location Address:
SUITE 145
Provider Business Practice Location Address City Name:
SPRING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77379-7580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-953-2782
Provider Business Practice Location Address Fax Number:
832-953-2784
Provider Enumeration Date:
03/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MASWOSWE
Authorized Official First Name:
JORDAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
713-446-6826

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 25425 , 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: 2119584 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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