Provider Demographics
NPI:1578285755
Name:LAS COLINAS PHYSICAL MEDICINE PLLC
Entity Type:Organization
Organization Name:LAS COLINAS PHYSICAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUDET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-462-9729
Mailing Address - Street 1:122 W JOHN CARPENTER FWY STE 105
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-2024
Mailing Address - Country:US
Mailing Address - Phone:972-378-0383
Mailing Address - Fax:972-403-3434
Practice Address - Street 1:122 W JOHN CARPENTER FWY STE 105
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-2024
Practice Address - Country:US
Practice Address - Phone:972-378-0383
Practice Address - Fax:972-403-3434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-14
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty