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General NPI Number Information
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NPI Number | 1124369459
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Entity Type | Organization
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Legal Business Name | DEHAVEN DIAGNOSTICS, LLC
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Dates
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Enumeration Date | 03/12/2013
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Last Update Date | 03/12/2013
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Provider Practice Location Address
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Address Line | 6116 OAKBEND TRL SUITE 106
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City | FORT WORTH
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State | TX
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Zip | 76132-3925
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Country | US
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Telephone | 817-984-6210
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Fax | 817-984-6216
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Provider Business Mailing Address
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Address Line | 6116 OAKBEND TRL SUITE 106
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City | FORT WORTH
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State | TX
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Zip | 76132-3925
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Country | US
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Telephone | 817-984-6210
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Fax | 817-984-6216
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. ROBERT JUDSON BALCH III
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Credential | D.O.
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Telephone | 817-984-6210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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