Healthcare Provider Details

I. General information

NPI: 1124594189
Provider Name (Legal Business Name): SWO MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6311 SOUTHWEST BLVD
BENBROOK TX
76132-1063
US

IV. Provider business mailing address

PO BOX 568
MUNCIE IN
47308-0568
US

V. Phone/Fax

Practice location:
  • Phone: 817-731-9400
  • Fax:
Mailing address:
  • Phone: 765-284-0493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH DANIELS
Title or Position: OWNER/AUTHORIZED OFFICIAL
Credential:
Phone: 765-284-0493