Provider Demographics
NPI:1275575755
Name:DFW SUPER GROUP I LLC
Entity Type:Organization
Organization Name:DFW SUPER GROUP I LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LANA
Authorized Official - Middle Name:S
Authorized Official - Last Name:RALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:214-632-3514
Mailing Address - Street 1:PO BOX 835850
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75083-5850
Mailing Address - Country:US
Mailing Address - Phone:972-680-1577
Mailing Address - Fax:972-690-9834
Practice Address - Street 1:3020 LEGACY DR
Practice Address - Street 2:STE. 100-399
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75023-8322
Practice Address - Country:US
Practice Address - Phone:214-632-3514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00558UMedicare ID - Type Unspecified