1962895631 NPI number — STANBRO HEALTHCARE GROUP LLC

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 1962895631 NPI number — STANBRO HEALTHCARE GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STANBRO HEALTHCARE GROUP LLC
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:
1962895631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1620 W NORTHWEST HWY
Provider Second Line Business Mailing Address:
STE. 100
Provider Business Mailing Address City Name:
GRAPEVINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76051-3177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-572-0009
Provider Business Mailing Address Fax Number:
817-720-1039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 E 15TH ST
Provider Second Line Business Practice Location Address:
SUITE 400C
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73013-6697
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-562-6434
Provider Business Practice Location Address Fax Number:
405-285-6121
Provider Enumeration Date:
03/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MISKIMINS
Authorized Official First Name:
TAMMIE
Authorized Official Middle Name:
Authorized Official Title or Position:
MGR., LICENSING & THIRD PARTY
Authorized Official Telephone Number:
817-572-0009

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 17167 , 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)

  • Identifier: 2150608 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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