Healthcare Provider Details

I. General information

NPI: 1073919494
Provider Name (Legal Business Name): DREAMLAND UAP ANESTHESIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 12/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 VILLAGE SQ
HAZELWOOD MO
63042-1820
US

IV. Provider business mailing address

15305 DALLAS PKWY 1600
ADDISON TX
75001-4637
US

V. Phone/Fax

Practice location:
  • Phone: 314-373-8931
  • Fax: 314-373-8935
Mailing address:
  • Phone: 972-713-3547
  • Fax: 972-534-1568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. KIMBERLY MICHELLE HARPER
Title or Position: OFFICER / ANESTHESIA PROGRAM MANAGE
Credential:
Phone: 972-713-3547