1174653695 NPI number — APEX SPORTS MEDICINE AND REHABILITATION ASSOCIATES, INC.

Table of content: (NPI 1174653695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174653695 NPI number — APEX SPORTS MEDICINE AND REHABILITATION ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
APEX SPORTS MEDICINE AND REHABILITATION ASSOCIATES, INC.
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:
1174653695
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2114 TEXOMA PKWY
Provider Second Line Business Mailing Address:
650
Provider Business Mailing Address City Name:
SHERMAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75090-2683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-813-1551
Provider Business Mailing Address Fax Number:
903-813-1725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2114 TEXOMA PKWY
Provider Second Line Business Practice Location Address:
650
Provider Business Practice Location Address City Name:
SHERMAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75090-2683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-813-1551
Provider Business Practice Location Address Fax Number:
903-813-1725
Provider Enumeration Date:
03/06/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KLEMENT
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
903-813-1551

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  649440000 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 649440000 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0015JC . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".