Healthcare Provider Details

I. General information

NPI: 1811406192
Provider Name (Legal Business Name): MSH DIAMONDBACK HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16219 RANCH ROAD 620
AUSTIN TX
78717
US

IV. Provider business mailing address

1320 ARROW POINT DR STE 506
CEDAR PARK TX
78613-2189
US

V. Phone/Fax

Practice location:
  • Phone: 512-673-8624
  • Fax:
Mailing address:
  • Phone: 512-524-7321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARK W FRITZ
Title or Position: PRESIDENT
Credential:
Phone: 512-524-7321