Healthcare Provider Details

I. General information

NPI: 1902033996
Provider Name (Legal Business Name): MISTY JUDSON CP, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6011 HARRY HINES BLVD. STE #V5.400
DALLAS TX
75390-9091
US

IV. Provider business mailing address

6011 HARRY HINES BLVD. STE #V5.400
DALLAS TX
75390-9091
US

V. Phone/Fax

Practice location:
  • Phone: 214-648-1530
  • Fax:
Mailing address:
  • Phone: 214-648-1530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number1333
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: