1891708004 NPI number — TARRANT COMMUNITY PEDIATRICS

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 1891708004 NPI number — TARRANT COMMUNITY PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TARRANT COMMUNITY PEDIATRICS
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:
6
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:
1891708004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1913 COUNTRY MOSS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHLAKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76092-6928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-595-9944
Provider Business Mailing Address Fax Number:
817-595-8835

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7290 GLENVIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHLAND HILLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76180-8610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-595-9944
Provider Business Practice Location Address Fax Number:
817-595-8835
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SUBRAMANIAN
Authorized Official First Name:
KALAIMANI
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-595-9944

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X , with the licence number: L0626 , 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: 165594601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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