1770942773 NPI number — NORTH TEXAS KIDNEY DISEASE ASSOCIATES

Table of content: (NPI 1770942773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770942773 NPI number — NORTH TEXAS KIDNEY DISEASE ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH TEXAS KIDNEY DISEASE ASSOCIATES
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:
1770942773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3315 COLORADO BLVD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
DENTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76210-6884
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-320-1708
Provider Business Mailing Address Fax Number:
940-565-5457

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4312 HERITAGE TRACE PKWY
Provider Second Line Business Practice Location Address:
SUITE 708
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-870-9941
Provider Business Practice Location Address Fax Number:
817-840-5881
Provider Enumeration Date:
02/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
VAUGHN
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
940-320-1708

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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