1871270124 NPI number — ESSENTIAL FAMILY PRACTICE OF WEST TEXAS PLLC

Table of content: (NPI 1871270124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871270124 NPI number — ESSENTIAL FAMILY PRACTICE OF WEST TEXAS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ESSENTIAL FAMILY PRACTICE OF WEST TEXAS 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:
1871270124
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21750 HARDY OAK BLVD STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78258-4946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6704 N LAGOW LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79762-3061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-978-3022
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2023

Additional Information

Authorized Official

Authorized Official Last Name:
DORMAN
Authorized Official First Name:
JACQUELYNN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/FAMILY NURSE PRACTITIONER
Authorized Official Telephone Number:
432-978-3022

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1013444892 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1962068981 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com