Healthcare Provider Details

I. General information

NPI: 1770541435
Provider Name (Legal Business Name): WEST TEXAS PROVIDER SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BARTLETT DR SUITE 108
EL PASO TX
79912-1628
US

IV. Provider business mailing address

200 BARTLETT DR SUITE 108
EL PASO TX
79912-1628
US

V. Phone/Fax

Practice location:
  • Phone: 915-581-7960
  • Fax: 915-584-7599
Mailing address:
  • Phone: 915-581-7960
  • Fax: 915-584-7599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number33BP3500X
License Number StateTX

VIII. Authorized Official

Name: DON D PENDERGRAS
Title or Position: PRESIDENT
Credential:
Phone: 915-581-6644