Provider Demographics
NPI:1730960501
Name:HEALTHSOURCE FSM & C
Entity type:Organization
Organization Name:HEALTHSOURCE FSM & C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:214-941-4903
Mailing Address - Street 1:211 E CLARENDON DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-2914
Mailing Address - Country:US
Mailing Address - Phone:214-941-4903
Mailing Address - Fax:214-941-4904
Practice Address - Street 1:211 E CLARENDON DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-2914
Practice Address - Country:US
Practice Address - Phone:214-941-4903
Practice Address - Fax:214-941-4904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-09
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty