MEDICARE: NDL DALLAS HOLDINGS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	293D00000X	Physiological Laboratory

General Provider Information

NPI Number	:	1295074557
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NDL DALLAS HOLDINGS, LLC

Provider Business Mailing Address
First Line	:	6510 ABRAMS RD
Second Line	:	STE 510
City	:	DALLAS
State	:	TX
Zip	:	75231-7217
Country	:	US
Telephone Number	:	214-363-3623
Fax Number	:	214-363-0869

Provider Business Practice Location Address
First Line	:	6510 ABRAMS RD
Second Line	:	STE 510
City	:	DALLAS
State	:	TX
Zip	:	75231-7217
Country	:	US
Telephone Number	:	214-363-3623
Fax Number	:	214-363-0869

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	ERICA BOEHLE
Credential	:
Telephone Number	:	602-424-4450

Provider Enumeration Date	:	02/06/2013
Last Update Date	:	11/20/2013

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