=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255832788
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUSTEN TRUETT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2018
-----------------------------------------------------
Last Update Date | 02/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 490 VAN ZANDT COUNTY ROAD 1226
-----------------------------------------------------
City | GRAND SALINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-352-9563
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 755 S BECKHAM AVE
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75701-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------