Provider Demographics
NPI:1821043225
Name:TEXOMA PICC STAT
Entity Type:Organization
Organization Name:TEXOMA PICC STAT
Other - Org Name:LUGENIA GIBBS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKING
Authorized Official - Suffix:
Authorized Official - Credentials:CMIS, CMOM
Authorized Official - Phone:940-781-8837
Mailing Address - Street 1:5308 PYRENEES DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-3949
Mailing Address - Country:US
Mailing Address - Phone:940-781-8837
Mailing Address - Fax:940-692-4136
Practice Address - Street 1:5308 PYRENEES DR
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76310-3949
Practice Address - Country:US
Practice Address - Phone:940-781-8837
Practice Address - Fax:940-692-4136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX619031174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherEIN