Healthcare Provider Details

I. General information

NPI: 1932494192
Provider Name (Legal Business Name): DEEP BLUE FIRST ASSIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W I-20
ARLINGTON TX
76017-5851
US

IV. Provider business mailing address

PO BOX 2626
FORT WORTH TX
76113-2626
US

V. Phone/Fax

Practice location:
  • Phone: 817-472-3675
  • Fax:
Mailing address:
  • Phone: 817-294-7444
  • Fax: 817-294-7172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number530175
License Number StateTX

VIII. Authorized Official

Name: MS. CECE PANNELL
Title or Position: OFF MGR
Credential:
Phone: 817-294-7444