=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336887181
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OCCUMED - ONSITE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2022
-----------------------------------------------------
Last Update Date | 05/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1329 MILLWOOD RD
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75069-7157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-494-1419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2046 FOREST LN STE 180
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75042-7939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-494-1419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF FINANCE
-----------------------------------------------------
Name | MATTHEW MIDDLEBROOK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-494-1419
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------