Provider Demographics
NPI:1538711361
Name:DALLAS-FORT WORTH SPINE INSTITUTE, LLC
Entity type:Organization
Organization Name:DALLAS-FORT WORTH SPINE INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROB
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-238-0512
Mailing Address - Street 1:6130 W PARKER RD STE 502
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-7993
Mailing Address - Country:US
Mailing Address - Phone:972-238-0512
Mailing Address - Fax:972-378-6925
Practice Address - Street 1:6130 W PARKER RD STE 502
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-7993
Practice Address - Country:US
Practice Address - Phone:972-238-0512
Practice Address - Fax:972-378-6925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX13219906OtherTEXAS DRIVERS LICENSE