1962903252 NPI number — MULTI SPECIALTY CLINIC OF TEXAS PLLC

Table of content: (NPI 1962903252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962903252 NPI number — MULTI SPECIALTY CLINIC OF TEXAS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MULTI SPECIALTY CLINIC OF TEXAS 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:
1962903252
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3453 SAINT FRANCIS AVE
Provider Second Line Business Mailing Address:
125
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75228-7199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-779-0884
Provider Business Mailing Address Fax Number:
469-779-0920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3453 SAINT FRANCIS AVE
Provider Second Line Business Practice Location Address:
125
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75228-7199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-779-0884
Provider Business Practice Location Address Fax Number:
469-779-0920
Provider Enumeration Date:
02/22/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MATHEW
Authorized Official First Name:
ALEYAMMA
Authorized Official Middle Name:
Authorized Official Title or Position:
FNP
Authorized Official Telephone Number:
469-779-0884

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  AP-133700 , 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: 1760911572 . This is a "NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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