1023099546 NPI number — THE EAGLE FORD CLINICS, PA

Table of content: (NPI 1023099546)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023099546 NPI number — THE EAGLE FORD CLINICS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE EAGLE FORD CLINICS, 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:
HOOD MEDICAL CLINICS
Provider Other Organization Name Type Code:
3
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:
1023099546
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 E MILLER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DILLEY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78017-3912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-965-1684
Provider Business Mailing Address Fax Number:
830-965-1278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 E MILLER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DILLEY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78017-3912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-965-1684
Provider Business Practice Location Address Fax Number:
830-965-1278
Provider Enumeration Date:
11/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DUTTA
Authorized Official First Name:
SURESH
Authorized Official Middle Name:
V
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
830-965-1684

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13506605 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 135106603 . This is a "TX HEALTH STEPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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