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General NPI Number Information
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NPI Number | 1932361441
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Entity Type | Organization
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Legal Business Name | LASER VAGINAL REJUVENATION INSTITUTE OF DALLAS PA
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Dates
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Enumeration Date | 06/26/2008
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Last Update Date | 06/26/2008
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Provider Practice Location Address
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Address Line | 9101 N CENTRAL EXPY SUITE 550
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City | DALLAS
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State | TX
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Zip | 75231-5927
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Country | US
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Telephone | 214-442-0055
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Fax | 214-442-0056
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Provider Business Mailing Address
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Address Line | 9101 N CENTRAL EXPY SUITE 550
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City | DALLAS
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State | TX
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Zip | 75231-5927
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Country | US
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Telephone | 214-442-0055
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Fax | 214-442-0056
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Authorized Official
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Title or Position | BILLING MGR
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Name | TAMMIE M JACKSON
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Credential |
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Telephone | 469-916-4767
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | K8880
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License Number State | TX
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