1801067269 NPI number — MSPF-IV RIDGEMAR OE, LP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801067269 NPI number — MSPF-IV RIDGEMAR OE, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MSPF-IV RIDGEMAR OE, LP
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:
6
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:
1801067269
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3811 TURTLE CREEK BLVD
Provider Second Line Business Mailing Address:
SUITE #1850
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75219-4402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-651-4050
Provider Business Mailing Address Fax Number:
214-651-4001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6600 LANDS END CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76116-2100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-665-1971
Provider Business Practice Location Address Fax Number:
817-665-1977
Provider Enumeration Date:
03/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RONCK
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-651-4050

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  116802 , 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: 5470 . This is a "MEDICAID VENDOR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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