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General NPI Number Information
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NPI Number | 1245665306
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Entity Type | Organization
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Legal Business Name | ORTHODOMICILE
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Dates
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Enumeration Date | 09/09/2013
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Last Update Date | 09/09/2013
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Provider Practice Location Address
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Address Line | 5510 SUMMERHILL RD
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City | TEXARKANA
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State | TX
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Zip | 75503-1822
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Country | US
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Telephone | 903-792-2710
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Fax |
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Provider Business Mailing Address
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Address Line | 5510 SUMMERHILL RD
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City | TEXARKANA
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State | TX
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Zip | 75503-1822
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Country | US
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Telephone | 903-792-2710
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Fax |
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Authorized Official
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Title or Position | BILLING SPECIALIST
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Name | JENNIFER O'BRIEN
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Credential |
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Telephone | 816-832-8804
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 180
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 1411
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License Number State | TX
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