Individual
MR. TOMMY LEE PROVOST
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
5832 MIDNIGHT LN, GRAND PRAIRIE, TX 75052-8585
(682) 465-5267
Mailing address
5832 MIDNIGHT LN, GRAND PRAIRIE, TX 75052-8585
(682) 465-5267
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
—
—
Other
Enumeration date
08/17/2015
Last updated
08/17/2015
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