Provider Demographics
NPI:1134471725
Name:UAP LEBANON ENDO, LLC
Entity Type:Organization
Organization Name:UAP LEBANON ENDO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-713-3547
Mailing Address - Street 1:15305 DALLAS PKWY
Mailing Address - Street 2:#1600
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4637
Mailing Address - Country:US
Mailing Address - Phone:972-713-3547
Mailing Address - Fax:972-534-1568
Practice Address - Street 1:100 PHYSICIANS WAY
Practice Address - Street 2:STE 340
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37090-8102
Practice Address - Country:US
Practice Address - Phone:615-466-9532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6023768OtherBCBS OF TENNESSE, INC.
TNQ008286Medicaid
TNQ008286Medicaid