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General NPI Number Information
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NPI Number | 1174496137
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Entity Type | Organization
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Legal Business Name | MARDESTRE
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Dates
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Enumeration Date | 09/25/2025
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Last Update Date | 09/25/2025
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Provider Practice Location Address
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Address Line | 2202 ROOK DR
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City | DALLAS
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State | TX
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Zip | 75211-1865
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Country | US
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Telephone | 972-922-7368
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Fax |
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Provider Business Mailing Address
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Address Line | 11816 INWOOD RD # 1066
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City | DALLAS
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State | TX
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Zip | 75244-8011
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CRANIAL PROTHESIS SPECIALIST
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Name | MARCIA CHAFFIN BROWN
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Credential |
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Telephone | 972-922-7368
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1744P3200X
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Taxonomy Name | Prosthetics Case Management
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License Number |
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License Number State |
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