1841936689 NPI number — RANDALL EDWARD MULRY

Table of content: RANDALL EDWARD MULRY (NPI 1841936689)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841936689 NPI number — RANDALL EDWARD MULRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MULRY
Provider First Name:
RANDALL
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1841936689
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3226 DUCHESS TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75229-5012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-587-0495
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1241 CROSS TIMBERS ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOWER MOUND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-691-3131
Provider Business Practice Location Address Fax Number:
972-691-3131
Provider Enumeration Date:
05/05/2022

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: 225100000X , with the licence number:  1132124 , 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: 1132124 . This is a "STATE LISCENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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