Provider Demographics
NPI:1285868372
Name:NORTH TEXAS SPORTS AND ORTHOPEDIC CENTER, PLLC
Entity Type:Organization
Organization Name:NORTH TEXAS SPORTS AND ORTHOPEDIC CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-401-8720
Mailing Address - Street 1:2020 W STATE HIGHWAY 114
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-8649
Mailing Address - Country:US
Mailing Address - Phone:817-310-0810
Mailing Address - Fax:817-812-3525
Practice Address - Street 1:2020 W STATE HIGHWAY 114
Practice Address - Street 2:SUITE 110
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8649
Practice Address - Country:US
Practice Address - Phone:817-310-0810
Practice Address - Fax:817-812-3525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-05
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX206596301Medicaid
TXDP1378OtherRR MEDICARE GROUP PTAN
TXP00755495OtherRAILROAD MEDICARE PTAN
TX0A4664Medicare PIN