Healthcare Provider Details

I. General information

NPI: 1134471725
Provider Name (Legal Business Name): UAP LEBANON ENDO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PHYSICIANS WAY STE 340
LEBANON TN
37090-8102
US

IV. Provider business mailing address

15305 DALLAS PKWY #1600
ADDISON TX
75001-4637
US

V. Phone/Fax

Practice location:
  • Phone: 615-466-9532
  • Fax:
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 State

VIII. Authorized Official

Name: KIMBERLY M HARPER
Title or Position: OFFICER/AUTHORIZED OFFICIAL
Credential:
Phone: 972-713-3547