=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386914083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH TEXAS PROVIDERS, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2012
-----------------------------------------------------
Last Update Date | 01/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 N CENTRAL EXPY
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75075-7100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-221-7117
-----------------------------------------------------
Fax | 972-271-2135
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 472308
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75047-2308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-221-7117
-----------------------------------------------------
Fax | 972-271-2135
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | ROSA CRUZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-221-7117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------