1750654984 NPI number — WEST TEXAS REGENERATIVE MEDICINE CLINIC

Table of content: (NPI 1750654984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750654984 NPI number — WEST TEXAS REGENERATIVE MEDICINE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST TEXAS REGENERATIVE MEDICINE CLINIC
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:
1750654984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3501 S SONCY
Provider Second Line Business Mailing Address:
STE 1001
Provider Business Mailing Address City Name:
AMARILLO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79119-3834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-367-8719
Provider Business Mailing Address Fax Number:
806-418-4329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 5TH AVE
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
CANYON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79015-3834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-655-4878
Provider Business Practice Location Address Fax Number:
806-655-8790
Provider Enumeration Date:
02/19/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DYER
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER-PROVIDER
Authorized Official Telephone Number:
806-367-8719

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: K5914 , 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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