Healthcare Provider Details

I. General information

NPI: 1033397062
Provider Name (Legal Business Name): DFW SURGICAL SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2521 LONE STAR LN
GRAPEVINE TX
76051-4535
US

IV. Provider business mailing address

PO BOX 186
GRAPEVINE TX
76099-0186
US

V. Phone/Fax

Practice location:
  • Phone: 817-480-1800
  • Fax: 817-251-0205
Mailing address:
  • Phone: 817-480-1800
  • Fax: 817-251-0205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License Number537082/686090
License Number StateTX

VIII. Authorized Official

Name: DR. JACKIE DEAN BONNER II
Title or Position: OWNER/MEMBER
Credential: DC
Phone: 817-480-1800