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General NPI Number Information
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NPI Number | 1023117157
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Entity Type | Organization
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Legal Business Name | CCST ASSOCIATES PLLC
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Dates
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Enumeration Date | 09/22/2006
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Last Update Date | 10/17/2007
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Provider Practice Location Address
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Address Line | 221 W COLORADO BLVD SUITE 100
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City | DALLAS
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State | TX
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Zip | 75208
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Country | US
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Telephone | 214-943-8605
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Fax | 214-941-3076
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Provider Business Mailing Address
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Address Line | 221 W COLORADO BLVD SUITE 100
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City | DALLAS
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State | TX
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Zip | 75208
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Country | US
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Telephone | 214-943-8605
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Fax | 214-941-3076
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Authorized Official
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Title or Position | TRAUMA SURGEON
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Name | ALICIA J MANGRAM
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Credential | M.D.
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Telephone | 214-943-8605
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | J8654
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License Number State | TX
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