Basic Information
| Provider Information | |||||||||
| NPI: | 1043576218 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 7872 INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 SUGAR CREEK CIR | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756052580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143346831 | ||||||||
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| Practice Location | |||||||||
| Address1: | 615 CLINIC DR | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756055172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032123105 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2012 | ||||||||
| LastUpdateDate: | 09/16/2022 | ||||||||
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| AuthorizedOfficialLastName: | PEDDIREDDY | ||||||||
| AuthorizedOfficialFirstName: | RUPA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2143925974 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
| NPICertificationDate: | 09/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0805X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
No ID Information.