1972731495 NPI number — BALCONES HEALTHCARE ASSOCIATES, PA

Table of content: HANNAH MERLE AGBUNAG NEWCOMER (NPI 1083495493)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972731495 NPI number — BALCONES HEALTHCARE ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALCONES HEALTHCARE ASSOCIATES, PA
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:
1972731495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 268969
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:
73126-8969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-868-4352
Provider Business Mailing Address Fax Number:
512-868-4354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 COUNTY ROAD 340A
Provider Second Line Business Practice Location Address:
BUILDING 1, SUITE 4
Provider Business Practice Location Address City Name:
BURNET
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78611-4537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-868-4352
Provider Business Practice Location Address Fax Number:
512-868-4354
Provider Enumeration Date:
06/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BURGEST
Authorized Official First Name:
SEAN
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
512-868-4352

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X , with the licence number:  L9637 , 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: 2128704-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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