=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962728261
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DALLAS FAMILY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2010
-----------------------------------------------------
Last Update Date | 04/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 920 S BOULEVARD # 103
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73034-4731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-245-7590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 920 S BOULEVARD # 103
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73034-4731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-245-7590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. WAYNE FRANKLIN DALLAS SR.
-----------------------------------------------------
Credential | MHR
-----------------------------------------------------
Telephone | 405-245-7590
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 2800
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------