=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366144123
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RED OAK DRUG CLINICAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2023
-----------------------------------------------------
Last Update Date | 03/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 S GRAND AVE STE 1
-----------------------------------------------------
City | WAXAHACHIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75165-2268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-938-3060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 S GRAND AVE STE 1
-----------------------------------------------------
City | WAXAHACHIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75165-2268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-938-3060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL/ OWNER
-----------------------------------------------------
Name | APRIL POWELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-938-3060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------