1821636564 NPI number — RADIANT DERMATOLOGY FALL CREEK PLLC

Table of content: (NPI 1821636564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821636564 NPI number — RADIANT DERMATOLOGY FALL CREEK PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RADIANT DERMATOLOGY FALL CREEK PLLC
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:
1821636564
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9240 N SAM HOUSTON PKWY E
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
HUMBLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77396
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-777-7559
Provider Business Mailing Address Fax Number:
832-777-7541

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9240 N SAM HOUSTON PKWY E
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
HUMBLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-777-7559
Provider Business Practice Location Address Fax Number:
832-777-7541
Provider Enumeration Date:
12/12/2019

Additional Information

Authorized Official

Authorized Official Last Name:
LE
Authorized Official First Name:
LIET
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
832-777-7559

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com