Organization
DO NOT USE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JODI KRUSELY (ACCOUNT MANAGER)
(847) 838-3832
Entity
Organization
Contact information
Practice address
912 W 12TH ST, DALLAS, TX 75208-6005
(214) 946-6400
(214) 946-6402
Mailing address
1231 GREENWAY DR, SUITE 120, IRVING, TX 75038-2533
(972) 580-7700
(972) 580-7715
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
—
Other
Enumeration date
08/24/2007
Last updated
01/31/2008
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