=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417065046
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CDG CARDIAC PROFILES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2570 ELDORADO PKWY SUITE 100
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75070-4365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-542-5122
-----------------------------------------------------
Fax | 469-742-0113
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3001 HARDIN BLVD PMB #210 SUITE 110
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75070-7489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-542-5122
-----------------------------------------------------
Fax | 469-742-0113
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. LINDA J STACIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-542-5122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246W00000X
-----------------------------------------------------
Taxonomy Name | Cardiology Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------