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General NPI Number Information
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NPI Number | 1952590077
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Entity Type | Organization
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Legal Business Name | FALL CREEK SURGICAL ASSISTANTS
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Dates
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Enumeration Date | 10/15/2007
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Last Update Date | 10/15/2007
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Provider Practice Location Address
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Address Line | 1504 KELSEY DR
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City | KELLER
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State | TX
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Zip | 76248-6878
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Country | US
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Telephone | 817-605-0991
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Fax | 817-605-0993
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Provider Business Mailing Address
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Address Line | PO BOX 820428
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City | NORTH RICHLAND HILLS
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State | TX
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Zip | 76182-0428
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Country | US
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Telephone | 817-605-0991
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Fax | 817-605-0993
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Authorized Official
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Title or Position | PRESIDENT
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Name | GREGORY B MCCLEERY
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Credential | LSA
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Telephone | 817-605-0991
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | SA00132
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License Number State | TX
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