Healthcare Provider Details

I. General information

NPI: 1760928576
Provider Name (Legal Business Name): 117 SURGICAL ASSISTANTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8840 CYPRESS WATERS BLVD STE 190
COPPELL TX
75019-4621
US

IV. Provider business mailing address

8840 CYPRESS WATERS BLVD STE 190
COPPELL TX
75019-4621
US

V. Phone/Fax

Practice location:
  • Phone: 817-485-5100
  • Fax:
Mailing address:
  • Phone: 817-485-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: CHARLES C NEFF
Title or Position: DIRECTOR
Credential:
Phone: 817-485-5100