Provider Demographics
NPI:1043491467
Name:DO NOT USE
Entity Type:Organization
Organization Name:DO NOT USE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUSELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-838-3832
Mailing Address - Street 1:1231 GREENWAY DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2533
Mailing Address - Country:US
Mailing Address - Phone:972-580-7700
Mailing Address - Fax:972-580-7715
Practice Address - Street 1:1706 W IRVING BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-7137
Practice Address - Country:US
Practice Address - Phone:972-254-1474
Practice Address - Fax:972-259-3037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care