Provider Demographics
NPI:1568456937
Name:DAFONTE MEDICAL SERVICES, LLC
Entity Type:Organization
Organization Name:DAFONTE MEDICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRANDEE
Authorized Official - Middle Name:NICOLA
Authorized Official - Last Name:DAFONTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-498-3566
Mailing Address - Street 1:1101 HIGHWAY 6 S
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-1021
Mailing Address - Country:US
Mailing Address - Phone:281-498-3566
Mailing Address - Fax:281-498-5388
Practice Address - Street 1:1101 HIGHWAY 6 S
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-1021
Practice Address - Country:US
Practice Address - Phone:281-498-3566
Practice Address - Fax:281-498-5388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000125335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX017127401Medicaid
TX011105601Medicaid
TX1289840001Medicare ID - Type UnspecifiedPROSTHETICS/DME