Healthcare Provider Details

I. General information

NPI: 1902830441
Provider Name (Legal Business Name): GREGORY SWAIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
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: 877-294-7444
  • 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:
Title or Position:
Credential:
Phone: