1770867111 NPI number — LITTLE ELM MEDICAL CLINIC PA

Table of content: (NPI 1770867111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770867111 NPI number — LITTLE ELM MEDICAL CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LITTLE ELM MEDICAL CLINIC 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:
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:
1770867111
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
730 E ELDORADO PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ELM
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75068-5444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-292-3330
Provider Business Mailing Address Fax Number:
214-619-4697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
730 E ELDORADO PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE ELM
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75068-5444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-292-3330
Provider Business Practice Location Address Fax Number:
214-619-4697
Provider Enumeration Date:
10/04/2011

Additional Information

Authorized Official

Authorized Official Last Name:
FLORES
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
GERARD
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
972-292-3330

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  J6432 , 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: 8B1341 . This is a "MEDICARE ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8131342 . This is a "MEDICARE ID" identifier . This identifiers is of the category "OTHER".




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