Provider Demographics
NPI:1568655892
Name:KEVIN UPTERGROVE
Entity type:Organization
Organization Name:KEVIN UPTERGROVE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:UPTERGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-988-2985
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:SABINAL
Mailing Address - State:TX
Mailing Address - Zip Code:78881-0509
Mailing Address - Country:US
Mailing Address - Phone:830-988-2985
Mailing Address - Fax:830-988-2140
Practice Address - Street 1:517 N. CENTER
Practice Address - Street 2:
Practice Address - City:SABINAL
Practice Address - State:TX
Practice Address - Zip Code:78881-0509
Practice Address - Country:US
Practice Address - Phone:830-988-2985
Practice Address - Fax:830-988-2140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF33136Medicare UPIN