1952368664 NPI number — GRAND PRAIRIE PEDIATRIC AND ALLERGY CLINIC INC

Table of content: (NPI 1952368664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952368664 NPI number — GRAND PRAIRIE PEDIATRIC AND ALLERGY CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND PRAIRIE PEDIATRIC AND ALLERGY CLINIC INC
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:
1952368664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7301 N COMANCHE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-721-8090
Provider Business Mailing Address Fax Number:
405-722-8529

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7301 N COMANCHE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-721-8090
Provider Business Practice Location Address Fax Number:
405-722-8529
Provider Enumeration Date:
04/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
PRES
Authorized Official Telephone Number:
405-721-8090

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  11030 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com