1700010964 NPI number — GUADALUPE FAMILY HEALTH, PA

Table of content: (NPI 1700010964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700010964 NPI number — GUADALUPE FAMILY HEALTH, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUADALUPE FAMILY HEALTH, 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:
DAVID M. RIDER, MD
Provider Other Organization Name Type Code:
5
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:
1700010964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1206
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEGUIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78156-1206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-379-7901
Provider Business Mailing Address Fax Number:
830-401-0437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1414 E WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEGUIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78155-5175
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-379-7901
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
RIDER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
830-379-7901

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  M8283 , 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: 2089765-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0076SK . This is a "BLUE CROSS BLUE SHIELD ID #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2089765-02 . This is a "MEDICAID FOR TEXAS HEALTH STEPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com