Provider Demographics
NPI:1437483583
Name:MISSION EAST DALLAS AND METROPLEX PROJECT, INC.
Entity Type:Organization
Organization Name:MISSION EAST DALLAS AND METROPLEX PROJECT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILTRAUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-682-8917
Mailing Address - Street 1:4550 GUS THOMASSON RD STE 40
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-1758
Mailing Address - Country:US
Mailing Address - Phone:972-682-8917
Mailing Address - Fax:
Practice Address - Street 1:4550 GUS THOMASSON RD SUITE 40
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150
Practice Address - Country:US
Practice Address - Phone:972-682-8917
Practice Address - Fax:214-206-3255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX283855901Medicaid