=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225543911
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL S FASANYA A&S SMOOTHRIDE,LLC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2017
-----------------------------------------------------
Last Update Date | 12/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6653 MCKINNEY RANCH PKWY APT 12208
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75070-2225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-679-1137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3001 S HARDIN BLVD STE 110-314
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75070-7736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-782-8220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172A00000X
-----------------------------------------------------
Taxonomy Name | Driver
-----------------------------------------------------
License Number | 802715611
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------