MEDICARE: KRSPATELPACK,LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1629468871
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KRSPATELPACK,LLC

Provider Business Mailing Address
First Line	:	1535 WEST MOCKINGBIRD LANE, SUITE #400
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75235
Country	:	US
Telephone Number	:	214-522-4640
Fax Number	:	214-522-4650

Provider Business Practice Location Address
First Line	:	1535 WEST MOCKINGBIRD LANE,
Second Line	:	SUITE #400
City	:	DALLAS
State	:	TX
Zip	:	75235
Country	:	US
Telephone Number	:	214-522-4640
Fax Number	:	214-522-4650

Authorized Official
Title or Position	:	OWNER
Name	:	DHIREN PATEL
Credential	:	DO
Telephone Number	:	214-522-4640

Provider Enumeration Date	:	01/27/2015
Last Update Date	:	01/27/2015

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