Healthcare Provider Details

I. General information

NPI: 1922714294
Provider Name (Legal Business Name): AEGIS GROUP PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2331 WESTSIDE BLVD SE
RIO RANCHO NM
87124-4765
US

IV. Provider business mailing address

2601 NETWORK BLVD STE 102
FRISCO TX
75034-9092
US

V. Phone/Fax

Practice location:
  • Phone: 800-444-6845
  • Fax: 479-478-2852
Mailing address:
  • Phone: 972-372-6779
  • Fax: 479-668-0872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MISTY S WILSON
Title or Position: CONTRACT & CREDENTIALING SPECIALIST
Credential:
Phone: 972-372-6779