1750448015 NPI number — DEKALB HEALTH CARE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750448015 NPI number — DEKALB HEALTH CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEKALB HEALTH CARE LLC
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:
1750448015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12520 FM 1840
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DE KALB
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75559-1929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-667-2572
Provider Business Mailing Address Fax Number:
903-667-5589

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12520 FM 1840
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DE KALB
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75559-1929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-667-2572
Provider Business Practice Location Address Fax Number:
903-667-5589
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REDD
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
REIMBURSEMENT SPECIALISTS
Authorized Official Telephone Number:
903-881-9432

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001003424 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4553 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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