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General NPI Number Information
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NPI Number | 1679123632
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Entity Type | Organization
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Legal Business Name | EQUILYST LLC.
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Dates
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Enumeration Date | 09/12/2019
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Last Update Date | 09/12/2019
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Provider Practice Location Address
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Address Line | 2909 CANTON ST STE C
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City | DALLAS
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State | TX
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Zip | 75226-3508
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Country | US
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Telephone | 214-984-3696
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Fax | 469-523-5503
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Provider Business Mailing Address
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Address Line | 3131 MAIN ST APT 122
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City | DALLAS
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State | TX
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Zip | 75226-1530
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Country | US
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Telephone | 337-580-0710
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. WILLIAM BLAKE YORK
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Credential | FNP-C
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Telephone | 337-580-0710
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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