Provider Demographics
NPI:1326265364
Name:CARDIOVASCULAR SUPPORT SERVICES
Entity Type:Organization
Organization Name:CARDIOVASCULAR SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PERFUSIONIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:GOODRICH
Authorized Official - Suffix:
Authorized Official - Credentials:LP, CCP
Authorized Official - Phone:214-824-2510
Mailing Address - Street 1:3409 WORTH STREET.
Mailing Address - Street 2:SUITE 725
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-0289
Mailing Address - Country:US
Mailing Address - Phone:214-824-2510
Mailing Address - Fax:214-826-0130
Practice Address - Street 1:3409 WORTH ST.
Practice Address - Street 2:STE. 725
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-0289
Practice Address - Country:US
Practice Address - Phone:214-824-2510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPF0541171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty