Healthcare Provider Details

I. General information

NPI: 1710366109
Provider Name (Legal Business Name): WARDELL DEAN III RPSGT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 05/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4031 E TEAL ESTATES CIR
FRESNO TX
77545-8852
US

IV. Provider business mailing address

4031 E TEAL ESTATES CIR
FRESNO TX
77545-8852
US

V. Phone/Fax

Practice location:
  • Phone: 713-498-6523
  • Fax:
Mailing address:
  • Phone: 713-498-6523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number21356
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: