1851917801 NPI number — FYZICAL CORPUS CHRISTI LLC

Table of content: (NPI 1851917801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851917801 NPI number — FYZICAL CORPUS CHRISTI LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FYZICAL CORPUS CHRISTI LLC
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:
1851917801
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4510 GRAND LAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORPUS CHRISTI
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78413-5267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-269-0242
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3201 AIRLINE RD STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78414-3571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-334-1033
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/24/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LOPEZ
Authorized Official First Name:
DIANA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER, OPERATIONS MANAGER
Authorized Official Telephone Number:
210-269-0242

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1932696721 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".