Healthcare Provider Details

I. General information

NPI: 1265122105
Provider Name (Legal Business Name): DANIEL RAYMOND HEIDRICH CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11450 US HIGHWAY 380 STE 130404
CROSS ROADS TX
76227-8315
US

IV. Provider business mailing address

11450 US HIGHWAY 380 STE 130
CROSSROADS TX
76227-8322
US

V. Phone/Fax

Practice location:
  • Phone: 214-227-2457
  • Fax: 214-764-0880
Mailing address:
  • Phone: 214-227-2457
  • Fax: 214-764-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number177997
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: