1902278336 NPI number — SCOTT & WHITE CLINIC

Table of content: (NPI 1902278336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902278336 NPI number — SCOTT & WHITE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SCOTT & WHITE CLINIC
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:
1902278336
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 844658
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:
75284-4658
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:
2405 S CLEAR CREEK RD
Provider Second Line Business Practice Location Address:
SUITE 350 3RD FLOOR, ROOM 3.177
Provider Business Practice Location Address City Name:
KILLEEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-618-1888
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CANTU
Authorized Official First Name:
ALICE
Authorized Official Middle Name:
Authorized Official Title or Position:
SYSTEM DIRECTOR, CBS
Authorized Official Telephone Number:
254-215-9719

Provider Taxonomy Codes

  • Taxonomy code: 237600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3571515-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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