MEDICARE: DST MANAGEMENT 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	246Z00000X	Other Specialist/Technologist

General Provider Information

NPI Number	:	1417357955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DST MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	19627 INTERSTATE 45
Second Line	:	STE 425
City	:	SPRING
State	:	TX
Zip	:	77388-6030
Country	:	US
Telephone Number	:	281-319-4910
Fax Number	:	832-663-9371

Provider Business Practice Location Address
First Line	:	19627 INTERSTATE 45
Second Line	:	STE 425
City	:	SPRING
State	:	TX
Zip	:	77388-6030
Country	:	US
Telephone Number	:	281-319-4910
Fax Number	:	832-663-9371

Authorized Official
Title or Position	:	CEO
Name	:	KIM HENRY
Credential	:
Telephone Number	:	281-319-4910

Provider Enumeration Date	:	09/03/2014
Last Update Date	:	09/03/2014

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Directions to “DST MANAGEMENT LLC ” Practice Location

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