1912069790 NPI number — JOHN R MOSS & ARCHIE P GILLIAM PTR

Table of content: (NPI 1912069790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912069790 NPI number — JOHN R MOSS & ARCHIE P GILLIAM PTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN R MOSS & ARCHIE P GILLIAM PTR
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:
1912069790
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 S MCGEE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BORGER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79007-4020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-273-5606
Provider Business Mailing Address Fax Number:
806-273-3272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 S MCGEE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BORGER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79007-4020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-273-5606
Provider Business Practice Location Address Fax Number:
806-273-3272
Provider Enumeration Date:
12/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOSS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
806-273-5606

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 091499601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 016497201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com