Healthcare Provider Details

I. General information

NPI: 1790179893
Provider Name (Legal Business Name): 247 OBGYN SURGICAL ASSISTING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 03/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4924 MARSH HARRIER AVE
GRAND PRAIRIE TX
75052-3057
US

IV. Provider business mailing address

4924 MARSH HARRIER AVE
GRAND PRAIRIE TX
75052-3057
US

V. Phone/Fax

Practice location:
  • Phone: 972-652-0705
  • Fax: 972-752-7889
Mailing address:
  • Phone: 972-652-0705
  • Fax: 972-752-7889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: RICARDO CHUJUTALLI
Title or Position: MANAGER/OWNER
Credential: CSA
Phone: 972-652-0705