Healthcare Provider Details

I. General information

NPI: 1093745242
Provider Name (Legal Business Name): GREGORY A SWAIM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9440 POPPY DR
DALLAS TX
75218-3652
US

IV. Provider business mailing address

6723 SANTA FE AVE
DALLAS TX
75223-1253
US

V. Phone/Fax

Practice location:
  • Phone: 817-294-7444
  • Fax:
Mailing address:
  • Phone: 877-294-7444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number89002
License Number StateTX

VIII. Authorized Official

Name: GREGORY SWAIM
Title or Position: PRESIDENT
Credential:
Phone: 877-294-7444