1790809036 NPI number — NORTH TEXAS KIDNEY DISEASE ASSOCIATES

Table of content: (NPI 1790809036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790809036 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:
1790809036
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3315 COLORADO BLVD STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76210-6885
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:
4240 INTERNATIONAL PKWY
Provider Second Line Business Practice Location Address:
STE. 154
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-574-0464
Provider Business Practice Location Address Fax Number:
469-574-0471
Provider Enumeration Date:
03/19/2007

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)

  • Identifier: 146883702 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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