Basic Information
| Provider Information | |||||||||
| NPI: | 1568655892 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KEVIN UPTERGROVE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SABINAL FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 509 | ||||||||
| Address2: | |||||||||
| City: | SABINAL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788810509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8309882985 | ||||||||
| FaxNumber: | 8309882140 | ||||||||
| Practice Location | |||||||||
| Address1: | 517 N. CENTER | ||||||||
| Address2: | |||||||||
| City: | SABINAL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788810509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8309882985 | ||||||||
| FaxNumber: | 8309882140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2007 | ||||||||
| LastUpdateDate: | 08/21/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | UPTERGROVE | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8309882985 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.