1013278779 NPI number — BROWNWOOD SMILECRAFTERS, PLLC

Table of content: (NPI 1013278779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013278779 NPI number — BROWNWOOD SMILECRAFTERS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROWNWOOD SMILECRAFTERS, 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:
1013278779
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3709 AUSTIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROWNWOOD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76801-6626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-646-0516
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3709 AUSTIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROWNWOOD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76801-6626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-646-0516
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BAYLESS
Authorized Official First Name:
JEANNE
Authorized Official Middle Name:
HANSEN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
325-673-8164

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  12014 , 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: 208670402 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com