1114072550 NPI number — PROFESSIONAL EMERGENCY SERVICE ASSOCIATION OF DESOTO

Table of content: (NPI 1114072550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114072550 NPI number — PROFESSIONAL EMERGENCY SERVICE ASSOCIATION OF DESOTO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL EMERGENCY SERVICE ASSOCIATION OF DESOTO
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:
6
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:
1114072550
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 153068
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75015-3068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-659-1234
Provider Business Mailing Address Fax Number:
972-827-0195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
911 N HAMPTON RD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
DESOTO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75115-3903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-283-0444
Provider Business Practice Location Address Fax Number:
972-283-4484
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ENNIS
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
972-659-1234

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QX0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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