Healthcare Provider Details

I. General information

NPI: 1982215158
Provider Name (Legal Business Name): COALGTMONI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 W PLANO PKWY STE 100
PLANO TX
75093-8201
US

IV. Provider business mailing address

6101 W PLANO PKWY STE 100
PLANO TX
75093-8201
US

V. Phone/Fax

Practice location:
  • Phone: 214-445-6959
  • Fax:
Mailing address:
  • Phone: 214-750-3646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: RICHARD JACKSON
Title or Position: MANAGER
Credential: MD
Phone: 214-750-3646