1821597964 NPI number — ILA PROCELL LMT

Table of content: ILA PROCELL LMT (NPI 1821597964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821597964 NPI number — ILA PROCELL LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROCELL
Provider First Name:
ILA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

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:
1821597964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 367
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOODY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76557-0367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-689-3513
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
407 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOODY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76557-3849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-689-3513
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/05/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MT031858 , 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: MT031858 . This is a "MASSAGE THERAPIST" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com