Healthcare Provider Details

I. General information

NPI: 1346021102
Provider Name (Legal Business Name): DTG II PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARQUETTE AVE NW STE 1200
ALBUQUERQUE NM
87102-5312
US

IV. Provider business mailing address

811 E KENT RD
GREENVILLE MI
48838-9791
US

V. Phone/Fax

Practice location:
  • Phone: 800-268-7713
  • Fax: 415-704-3294
Mailing address:
  • Phone: 800-268-7713
  • Fax: 415-704-3294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KANDY MORRIS
Title or Position: SVP OF MANAGED CARE
Credential:
Phone: 877-795-2361