=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134426919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INGENIOS HEALTH CO.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2011
-----------------------------------------------------
Last Update Date | 11/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 LEGACY DR SUITE 206
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75034-5983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-704-7263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 LEGACY DR SUITE 206
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75034-5983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-704-7263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. KYLE TALCOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-294-5194
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------