=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164263109
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE SUPPLE TOUCH SURGICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2024
-----------------------------------------------------
Last Update Date | 12/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 809 SILVERTON ST
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-3854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-454-0944
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 938
-----------------------------------------------------
City | ROWLETT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75030-0938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-227-2457
-----------------------------------------------------
Fax | 214-764-0880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CSFA
-----------------------------------------------------
Name | JOEL MICAH SUPPLE
-----------------------------------------------------
Credential | CSFA
-----------------------------------------------------
Telephone | 817-454-0944
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------