Provider Demographics
NPI:1235683921
Name:PANTHEON MEDICAL LLC
Entity Type:Organization
Organization Name:PANTHEON MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:H
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-954-0406
Mailing Address - Street 1:9535 FOREST LN
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-5900
Mailing Address - Country:US
Mailing Address - Phone:214-954-0406
Mailing Address - Fax:
Practice Address - Street 1:9535 FOREST LN
Practice Address - Street 2:SUITE 100A
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-5900
Practice Address - Country:US
Practice Address - Phone:214-954-0406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes331L00000XSuppliersBlood Bank