Provider Demographics
NPI:1629134440
Name:EXECUTIVE DE-TAILS
Entity Type:Organization
Organization Name:EXECUTIVE DE-TAILS
Other - Org Name:EXECUTIVE DE-TAILS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:AIDELOJIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-274-2284
Mailing Address - Street 1:2952 CELIAN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-8737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2952 CELIAN DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-8737
Practice Address - Country:US
Practice Address - Phone:817-247-5267
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty