1740319920 NPI number — KENT WISE OD PA

Table of content: (NPI 1740319920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740319920 NPI number — KENT WISE OD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENT WISE OD PA
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:
1740319920
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1169 N BURLESON BLVD
Provider Second Line Business Mailing Address:
SUITE 131
Provider Business Mailing Address City Name:
BURLESON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-426-6060
Provider Business Mailing Address Fax Number:
817-426-2978

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1169 N BURLESON BLVD
Provider Second Line Business Practice Location Address:
SUITE 131
Provider Business Practice Location Address City Name:
BURLESON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-426-6060
Provider Business Practice Location Address Fax Number:
817-426-2978
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WISE
Authorized Official First Name:
KENT
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OD PRESIDENT
Authorized Official Telephone Number:
817-426-6060

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: TX4896 , 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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