Provider Demographics
NPI:1710555859
Name:MEDI-TAKE
Entity Type:Organization
Organization Name:MEDI-TAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SIDDIG
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-667-1390
Mailing Address - Street 1:2704 ATRIUM DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-7015
Mailing Address - Country:US
Mailing Address - Phone:469-667-1390
Mailing Address - Fax:
Practice Address - Street 1:2704 ATRIUM DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-7015
Practice Address - Country:US
Practice Address - Phone:469-667-1390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date: