Provider Demographics
NPI:1316329584
Name:THE MONTAGUE COUNTY CARPENTER'S SHOP, INC.
Entity type:Organization
Organization Name:THE MONTAGUE COUNTY CARPENTER'S SHOP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:CULPEPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-825-3148
Mailing Address - Street 1:400 BOSTON ST
Mailing Address - Street 2:
Mailing Address - City:NOCONA
Mailing Address - State:TX
Mailing Address - Zip Code:76255-3531
Mailing Address - Country:US
Mailing Address - Phone:940-825-3148
Mailing Address - Fax:940-825-3149
Practice Address - Street 1:400 BOSTON ST
Practice Address - Street 2:
Practice Address - City:NOCONA
Practice Address - State:TX
Practice Address - Zip Code:76255-3531
Practice Address - Country:US
Practice Address - Phone:940-825-3148
Practice Address - Fax:940-825-3149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001015352Medicaid