1831354638 NPI number — DEER OAKS MISSOURI

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 1831354638 NPI number — DEER OAKS MISSOURI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEER OAKS MISSOURI
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:
1831354638
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7272 WURZBACH RD
Provider Second Line Business Mailing Address:
SUITE 601
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78240-4801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-615-3472
Provider Business Mailing Address Fax Number:
210-593-9863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4741 CENTRAL ST
Provider Second Line Business Practice Location Address:
SUITE 494
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64112-1533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-561-2759
Provider Business Practice Location Address Fax Number:
210-593-9863
Provider Enumeration Date:
07/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BOSKIND
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
210-615-3472

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 507527208 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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