Provider Demographics
NPI:1114072550
Name:PROFESSIONAL EMERGENCY SERVICE ASSOCIATION OF DESOTO
Entity Type:Organization
Organization Name:PROFESSIONAL EMERGENCY SERVICE ASSOCIATION OF DESOTO
Other - Org Name:ECCARE HEALTH CENTER OF DESOTO
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:P
Authorized Official - Last Name:ENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-659-1234
Mailing Address - Street 1:PO BOX 153068
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75015-3068
Mailing Address - Country:US
Mailing Address - Phone:972-659-1234
Mailing Address - Fax:972-827-0195
Practice Address - Street 1:911 N HAMPTON RD
Practice Address - Street 2:SUITE 120
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-3903
Practice Address - Country:US
Practice Address - Phone:972-283-0444
Practice Address - Fax:972-283-4484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care