Basic Information
| Provider Information | |||||||||
| NPI: | 1568835569 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMPLETE EMERGENCY CARE LA VERNIA LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | THE EMERGENCY CLINIC AT LA VERNIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 92275 | ||||||||
| Address2: | |||||||||
| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760920103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174210034 | ||||||||
| FaxNumber: | 8174210036 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 S FM 1346 | ||||||||
| Address2: | 102 | ||||||||
| City: | LA VERNIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781214282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174210034 | ||||||||
| FaxNumber: | 8174210036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2015 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEIMAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | BRAXTON | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 8174210034 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | ESQ. | ||||||||
| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | Y | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
No ID Information.