1992980411 NPI number — STAT SERVICES OF JASPER COUNTY A, LLP

Table of content: (NPI 1992980411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992980411 NPI number — STAT SERVICES OF JASPER COUNTY A, LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STAT SERVICES OF JASPER COUNTY A, LLP
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:
1992980411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 552
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAUMONT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77704-0552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-833-3834
Provider Business Mailing Address Fax Number:
409-833-2060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2418 N WHEELER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75951-2115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-833-3834
Provider Business Practice Location Address Fax Number:
409-833-2060
Provider Enumeration Date:
01/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CARROLL
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
B
Authorized Official Title or Position:
DIRECTOR BILLING/ OWNER
Authorized Official Telephone Number:
409-833-3834

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  121101 , 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: 187748201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: GTPA1 . This is a "GTPA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: AMB697 . This is a "BC/BS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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