=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902842404
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CSK MEDICAL PARTNERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2006
-----------------------------------------------------
Last Update Date | 06/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4110 22ND PL
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79410-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-792-4329
-----------------------------------------------------
Fax | 806-792-9466
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4110 22ND PL
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79410-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-792-4329
-----------------------------------------------------
Fax | 806-792-9466
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. ROBERT THOMAS HENDRICKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 806-792-4329
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------