Provider Demographics
NPI:1497208854
Name:MY1PHP
Entity Type:Organization
Organization Name:MY1PHP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:SPRING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-875-8031
Mailing Address - Street 1:5131 BRYCE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-3611
Mailing Address - Country:US
Mailing Address - Phone:817-875-8031
Mailing Address - Fax:
Practice Address - Street 1:5131 BRYCE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-3611
Practice Address - Country:US
Practice Address - Phone:817-875-8031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUROAKSHEALTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service