1982641874 NPI number — DIGESTIVE HEALTH CLINIC OF EL PASO P A

Table of content: MRS. KIMBERLY DAWN IRELAND MS CCC SLP (NPI 1073637716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982641874 NPI number — DIGESTIVE HEALTH CLINIC OF EL PASO P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIGESTIVE HEALTH CLINIC OF EL PASO P A
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:
1982641874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
SUITE 4A 1250 E. CLIFF DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79902-4850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-541-7000
Provider Business Mailing Address Fax Number:
915-541-7002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SUITE 4A 1250 E. CLIFF DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79902-4850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-541-7000
Provider Business Practice Location Address Fax Number:
915-541-7002
Provider Enumeration Date:
06/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOLLI
Authorized Official First Name:
VENKATESWARA
Authorized Official Middle Name:
RAO
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
915-433-3924

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  J 5805 , 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: 119036501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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