Provider Demographics
NPI:1831109941
Name:TRICARE MEDICAL
Entity Type:Organization
Organization Name:TRICARE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER GEN MGR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:D
Authorized Official - Last Name:LAWLESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-894-0144
Mailing Address - Street 1:PO BOX 476
Mailing Address - Street 2:
Mailing Address - City:LEVELLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79336-0476
Mailing Address - Country:US
Mailing Address - Phone:806-894-0144
Mailing Address - Fax:806-894-6777
Practice Address - Street 1:120 CLUBVIEW DR
Practice Address - Street 2:
Practice Address - City:LEVELLAND
Practice Address - State:TX
Practice Address - Zip Code:79336-6304
Practice Address - Country:US
Practice Address - Phone:806-894-0144
Practice Address - Fax:806-894-6777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX106613100OtherFIRST CARE
TX509656OtherBLUE CROSS BLUE SHIELD
TX086965301Medicaid
TX015824801Medicaid
TX015824801Medicaid