1912145400 NPI number — EMERALD PALACE PRACTICE PLLC

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 1912145400 NPI number — EMERALD PALACE PRACTICE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMERALD PALACE PRACTICE 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:
1912145400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 863
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75013-0014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-866-9529
Provider Business Mailing Address Fax Number:
469-241-0556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6200 CHASE OAKS BLVD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75023-4652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-866-9529
Provider Business Practice Location Address Fax Number:
469-241-0556
Provider Enumeration Date:
01/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GRANDJEAN
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
LICENSED PROFESSIONAL COUNSELOR
Authorized Official Telephone Number:
214-866-9529

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  197756 , 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: 181137402 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com