Provider Demographics
NPI:1003025784
Name:PRUDENTIAL MEDICAL NETWORK, LP
Entity Type:Organization
Organization Name:PRUDENTIAL MEDICAL NETWORK, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:OPA-C
Authorized Official - Phone:817-714-9066
Mailing Address - Street 1:5455 HONEYSUCKLE RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-7006
Mailing Address - Country:US
Mailing Address - Phone:972-567-9571
Mailing Address - Fax:817-563-6934
Practice Address - Street 1:5455 HONEYSUCKLE RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-7006
Practice Address - Country:US
Practice Address - Phone:972-567-9571
Practice Address - Fax:817-563-6934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies