Healthcare Provider Details

I. General information

NPI: 1417379447
Provider Name (Legal Business Name): WEST STATE MHT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 PEAVY RD
LEESVILLE LA
71446-9514
US

IV. Provider business mailing address

1515 HERITAGE DR SUITE 110
MCKINNEY TX
75069-3379
US

V. Phone/Fax

Practice location:
  • Phone: 855-860-2109
  • Fax:
Mailing address:
  • Phone: 855-860-2109
  • Fax: 855-814-8428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11865R
License Number StateLA

VIII. Authorized Official

Name: STEVEN SMITH
Title or Position: MANAGER OF REGULATORY COMPLIANCE
Credential:
Phone: 855-860-2109