1730628405 NPI number — FAST LANE EMERGENCY ROOM, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730628405 NPI number — FAST LANE EMERGENCY ROOM, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAST LANE EMERGENCY ROOM, 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:
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:
1730628405
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4904 BELLAIRE DR S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76109-3101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-707-0985
Provider Business Mailing Address Fax Number:
817-977-1265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4000 N MACARTHUR BLVD
Provider Second Line Business Practice Location Address:
100A
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75038-6418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-995-2546
Provider Business Practice Location Address Fax Number:
469-995-2517
Provider Enumeration Date:
02/15/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BROWND
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
N
Authorized Official Title or Position:
CHIEF MANAGER
Authorized Official Telephone Number:
214-707-0985

Provider Taxonomy Codes

  • Taxonomy code: 261QE0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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