Provider Demographics
NPI:1104137322
Name:POWELL PROFESSIONAL OF WEST TEXAS, LLC
Entity type:Organization
Organization Name:POWELL PROFESSIONAL OF WEST TEXAS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-733-0010
Mailing Address - Street 1:1239 BOWIE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:TX
Mailing Address - Zip Code:78934-2343
Mailing Address - Country:US
Mailing Address - Phone:979-733-0010
Mailing Address - Fax:979-733-0051
Practice Address - Street 1:1501 4TH ST
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-4430
Practice Address - Country:US
Practice Address - Phone:325-643-4840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-23
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1004693416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100469OtherTEXAS DEPARTMENT OF STATE HEALTH SERVICES