Provider Demographics
NPI:1326397902
Name:DAVID OVERSTREET'S TAEKWONDO PLUS LLC
Entity Type:Organization
Organization Name:DAVID OVERSTREET'S TAEKWONDO PLUS LLC
Other - Org Name:OVERSTREET TAEKWONDO ACADEMY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF TRAINER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:OVERSTREET
Authorized Official - Suffix:
Authorized Official - Credentials:CTT
Authorized Official - Phone:575-439-5425
Mailing Address - Street 1:1600 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-5047
Mailing Address - Country:US
Mailing Address - Phone:575-439-5425
Mailing Address - Fax:575-439-5425
Practice Address - Street 1:1600 10TH ST
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5047
Practice Address - Country:US
Practice Address - Phone:575-439-5425
Practice Address - Fax:575-439-5425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare