Basic Information
| Provider Information | |||||||||
| NPI: | 1932611969 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER LUBBOCK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794300002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067433490 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4102 24TH ST STE 507 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794101805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067437980 | ||||||||
| FaxNumber: | 8067431290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2017 | ||||||||
| LastUpdateDate: | 12/27/2017 | ||||||||
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| AuthorizedOfficialLastName: | MAGERS | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSISTANT DEAN OF FINANCE ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 8067431830 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 140327146 | 05 | TX | MEDICAID | 084589302 | 05 | TX | MEDICAID |