1437483583 NPI number — MISSION EAST DALLAS AND METROPLEX PROJECT, INC.

Table of content: (NPI 1437483583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437483583 NPI number — MISSION EAST DALLAS AND METROPLEX PROJECT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSION EAST DALLAS AND METROPLEX PROJECT, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437483583
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4550 GUS THOMASSON RD STE 40
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESQUITE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75150-1758
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-682-8917
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4550 GUS THOMASSON RD SUITE 40
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESQUITE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-682-8917
Provider Business Practice Location Address Fax Number:
214-206-3255
Provider Enumeration Date:
09/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WILTRAUT
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
972-682-8917

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 283855901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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