Healthcare Provider Details

I. General information

NPI: 1649512294
Provider Name (Legal Business Name): AMBULATORY SURGICAL INSTITUTE OF DALLAS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2013
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17051 DALLAS PARKWAY SUITE 100
ADDISON TX
75001
US

IV. Provider business mailing address

PO BOX 674348
DALLAS TX
75267-4348
US

V. Phone/Fax

Practice location:
  • Phone: 469-916-0521
  • Fax: 972-234-0212
Mailing address:
  • Phone: 469-916-0521
  • Fax: 972-234-0212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number130152
License Number StateTX

VIII. Authorized Official

Name: TRACY WALLS
Title or Position: MANAGER
Credential:
Phone: 972-234-4740