Healthcare Provider Details

I. General information

NPI: 1235335258
Provider Name (Legal Business Name): MID-CITIES SURGICAL FIRST ASST. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2912 BOURBON ST
FORT WORTH TX
76123-1624
US

IV. Provider business mailing address

2912 BOURBON ST
FORT WORTH TX
76123-1624
US

V. Phone/Fax

Practice location:
  • Phone: 817-423-1969
  • Fax: 817-361-7954
Mailing address:
  • Phone: 817-423-1969
  • Fax: 817-361-7954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberSA00142
License Number StateTX

VIII. Authorized Official

Name: MR. VICTOR LAROSA RUFFIN SR.
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: LSA CFA
Phone: 817-423-1969