Provider Demographics
NPI:1497134258
Name:INVALID NAM
Entity Type:Organization
Organization Name:INVALID NAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:INVALID
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:INVALID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-406-3030
Mailing Address - Street 1:12400 W HWY 71 BLDG F
Mailing Address - Street 2:
Mailing Address - City:BEE CAVE
Mailing Address - State:TX
Mailing Address - Zip Code:78738-6517
Mailing Address - Country:US
Mailing Address - Phone:512-406-3030
Mailing Address - Fax:
Practice Address - Street 1:12400 W HWY 71 BLDG F
Practice Address - Street 2:
Practice Address - City:BEE CAVE
Practice Address - State:TX
Practice Address - Zip Code:78738-6517
Practice Address - Country:US
Practice Address - Phone:512-406-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7302146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response AttendantGroup - Single Specialty