Healthcare Provider Details

I. General information

NPI: 1801321112
Provider Name (Legal Business Name): CGC ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 W GREEN OAKS BLVD # 305-489
ARLINGTON TX
76016-4462
US

IV. Provider business mailing address

4101 W GREEN OAKS BLVD # 305-489
ARLINGTON TX
76016-4462
US

V. Phone/Fax

Practice location:
  • Phone: 817-264-6267
  • Fax:
Mailing address:
  • Phone: 817-264-6267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number802619502
License Number StateTX

VIII. Authorized Official

Name: MR. COREY SHEPARD
Title or Position: REGIONAL MANAGER
Credential:
Phone: 817-264-6267