Provider Demographics
NPI:1235571340
Name:GREAT SOUTHWEST MEDICAL LLC
Entity Type:Organization
Organization Name:GREAT SOUTHWEST MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:GUITREAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-382-1909
Mailing Address - Street 1:643 S GREAT SOUTHWEST PKWY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-1056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:643 S GREAT SOUTHWEST PKWY
Practice Address - Street 2:SUITE 104
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1056
Practice Address - Country:US
Practice Address - Phone:214-363-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0566261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF87395Medicare UPIN