Provider Demographics
NPI:1538243118
Name:DALLAS METRO PROFESSIONAL HEALTHCARE AGENCY
Entity type:Organization
Organization Name:DALLAS METRO PROFESSIONAL HEALTHCARE AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:A
Authorized Official - Last Name:ODUEZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-905-9681
Mailing Address - Street 1:5415 MAPLE AVE
Mailing Address - Street 2:SUITE 217
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-7432
Mailing Address - Country:US
Mailing Address - Phone:214-905-9681
Mailing Address - Fax:214-905-9164
Practice Address - Street 1:5415 MAPLE AVE
Practice Address - Street 2:SUITE 217
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7432
Practice Address - Country:US
Practice Address - Phone:214-905-9681
Practice Address - Fax:214-905-9164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX009740251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX677903Medicare ID - Type Unspecified