1295065118 NPI number — LOVERS LANE WELLNESS CENTER LLC

Table of content: (NPI 1295065118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295065118 NPI number — LOVERS LANE WELLNESS CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOVERS LANE WELLNESS CENTER LLC
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:
1295065118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3844 MARTHA LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75229-6126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-351-3904
Provider Business Mailing Address Fax Number:
214-351-2072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12800 PRESTON RD.
Provider Second Line Business Practice Location Address:
STE. 201
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-351-2299
Provider Business Practice Location Address Fax Number:
214-351-1122
Provider Enumeration Date:
12/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
TISKO
Authorized Official First Name:
KATHLEEN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
214-766-0589

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  10106 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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