1730365651 NPI number — TRANQUILITY HEALTH CENTERS, PC

Table of content: (NPI 1730365651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730365651 NPI number — TRANQUILITY HEALTH CENTERS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRANQUILITY HEALTH CENTERS, PC
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:
1730365651
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12410
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLEGE STATION
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77842-2410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-774-5300
Provider Business Mailing Address Fax Number:
979-776-5173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1121 BRIARCREST DR
Provider Second Line Business Practice Location Address:
SUITE #100
Provider Business Practice Location Address City Name:
BRYAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77802-2505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-268-0786
Provider Business Practice Location Address Fax Number:
979-846-2136
Provider Enumeration Date:
01/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LLOYD
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
979-774-5300

Provider Taxonomy Codes

  • Taxonomy code: 111NR0400X , with the licence number:  8580 , 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: 0025QW . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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