1801036686 NPI number — VICTOR SONGBANDITH LLC

Table of content: (NPI 1801036686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801036686 NPI number — VICTOR SONGBANDITH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICTOR SONGBANDITH 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:
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:
1801036686
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3022 TRAWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79936-4329
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-241-4734
Provider Business Mailing Address Fax Number:
915-855-3311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 NORTH ERMA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESIDIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79845-0693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-229-4246
Provider Business Practice Location Address Fax Number:
432-229-4249
Provider Enumeration Date:
03/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SONGBANDITH
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
915-241-4734

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  L0612 , 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: 213263102 . This is a "MEDICAID PART B" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 673912 . This is a "MEDICARE PART A PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 213263101 . This is a "MEDICAID PART A" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TXB161127 . This is a "MEDICARE PART B" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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