Healthcare Provider Details

I. General information

NPI: 1740742402
Provider Name (Legal Business Name): OTX CARE OF TX IV, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 MAIN ST STE 115
HOUSTON TX
77002-6502
US

IV. Provider business mailing address

102 WOODMONT BLVD STE 350
NASHVILLE TN
37205-2216
US

V. Phone/Fax

Practice location:
  • Phone: 615-386-0064
  • Fax:
Mailing address:
  • Phone: 615-386-0064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: EDWARD LELAND HUTTON EADIE
Title or Position: DIRECTOR
Credential:
Phone: 615-733-2064