1922455674 NPI number — PHYLLIS BOB-HARRIS

Table of content: PHYLLIS BOB-HARRIS (NPI 1922455674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922455674 NPI number — PHYLLIS BOB-HARRIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOB-HARRIS
Provider First Name:
PHYLLIS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOB HARRIS
Provider Other First Name:
PHYLLIS
Provider Other Middle Name:
YVETTE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LVN
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1922455674
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2108 PETUNIA ST
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:
75228-5685
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-748-8485
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2108 PETUNIA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75228-5685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-748-8485
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164X00000X , with the licence number:  202483 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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