1811175656 NPI number — GERALD ANAKWENZE

Table of content: (NPI 1811175656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811175656 NPI number — GERALD ANAKWENZE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERALD ANAKWENZE
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:
1811175656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 N TOWN EAST BLVD
Provider Second Line Business Mailing Address:
#138-248
Provider Business Mailing Address City Name:
MESQUITE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75150-4157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-529-4823
Provider Business Mailing Address Fax Number:
310-872-5317

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15330 LBJ FWY
Provider Second Line Business Practice Location Address:
#1061
Provider Business Practice Location Address City Name:
MESQUITE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75150-1223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-529-4823
Provider Business Practice Location Address Fax Number:
310-872-5317
Provider Enumeration Date:
02/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ANAKWENZE
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
310-529-4823

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  1000093 , 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: 1000093 . This is a "STATE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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