=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285044016
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON DANIEL MCCOY LMT, SLT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2014
-----------------------------------------------------
Last Update Date | 05/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 925 W PIONEER PKWY SUITE D.
-----------------------------------------------------
City | GRAND PRAIRIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75051-4735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-412-2079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 925 W PIONEER PKWY SUITE D.
-----------------------------------------------------
City | GRAND PRAIRIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75051-4735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-412-2079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MT107088
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number | ZP10218
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------