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NPI Code Detail

MEDICARE: IDT ENTERPRISE LLC

MEDICARE: IDT ENTERPRISE 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
1261QX0100XOccupational Medicine Clinic/Center
2103K00000XBehavior Analyst

General Provider Information

NPI Number : 1396422036
Entity Type Code : Organization
Provider Name (Legal Business Name) : IDT ENTERPRISE LLC
Provider Business Mailing Address
First Line : 1106 CORDOVA ST
Second Line :
City : MANSFIELD
State : TX
Zip : 76063-3198
Country : US
Telephone Number : 682-201-7934
Fax Number :
Provider Business Practice Location Address
First Line : 1510 N HAMPTON RD STE 150
Second Line :
City : DESOTO
State : TX
Zip : 75115-8324
Country : US
Telephone Number : 682-201-7934
Fax Number :
Authorized Official
Title or Position : CEO
Name : TELEMA NGA
Credential :
Telephone Number : 682-201-7934
Provider Enumeration Date : 07/04/2023
Last Update Date : 10/31/2023

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Directions to “IDT ENTERPRISE LLC ” Practice Location

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