Provider Demographics
NPI:1033219175
Name:PETTICOAT FAIR INC
Entity Type:Organization
Organization Name:PETTICOAT FAIR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-454-2900
Mailing Address - Street 1:PO BOX 10676
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78766-1676
Mailing Address - Country:US
Mailing Address - Phone:512-454-2900
Mailing Address - Fax:512-454-3381
Practice Address - Street 1:7739 NORTHCROSS DR
Practice Address - Street 2:SUITE M
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-1700
Practice Address - Country:US
Practice Address - Phone:512-454-2900
Practice Address - Fax:512-454-3381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0434550001Medicare ID - Type Unspecified