Healthcare Provider Details

I. General information

NPI: 1114144102
Provider Name (Legal Business Name): MAD DOG ENTERPRISES LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 W TEXAS AVE
WASKOM TX
75692-9113
US

IV. Provider business mailing address

390 W TEXAS AVE
WASKOM TX
75692-9113
US

V. Phone/Fax

Practice location:
  • Phone: 903-687-2500
  • Fax:
Mailing address:
  • Phone: 903-687-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH LEE VOLK
Title or Position: VICE PRESIDENT
Credential: PA-C
Phone: 903-687-2500