Healthcare Provider Details

I. General information

NPI: 1669976528
Provider Name (Legal Business Name): KRISTI B BAGNELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2304 JUDSON RD STE D
LONGVIEW TX
75605-4675
US

IV. Provider business mailing address

2304 JUDSON RD STE D
LONGVIEW TX
75605-4675
US

V. Phone/Fax

Practice location:
  • Phone: 903-212-6060
  • Fax:
Mailing address:
  • Phone: 903-212-6060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL BAGNELL
Title or Position: MANAGER
Credential:
Phone: 305-587-9062