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General NPI Number Information
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NPI Number | 1588144893
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Entity Type | Organization
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Legal Business Name | SOUTHLAKE DOCTORS EXPRESS, PA PSC
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Dates
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Enumeration Date | 08/16/2018
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Last Update Date | 04/03/2019
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Provider Practice Location Address
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Address Line | 325 CENTRAL EXPY S
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City | ALLEN
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State | TX
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Zip | 75013-2786
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Country | US
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Telephone | 469-640-4232
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Fax | 469-854-6453
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Provider Business Mailing Address
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Address Line | 2315 E SOUTHLAKE BLVD STE 110
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6684
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Country | US
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Telephone | 817-488-9922
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Fax | 817-488-8917
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Authorized Official
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Title or Position | CEO
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Name | MR. JUSTIN M. RAINS
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Credential | JD
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Telephone | 817-488-9922
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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