Provider Demographics
NPI:1750643730
Name:PICC LINE PROFESSIONAL GROUP, INC.
Entity Type:Organization
Organization Name:PICC LINE PROFESSIONAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:DILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:512-573-3531
Mailing Address - Street 1:PO BOX 225
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78667-0225
Mailing Address - Country:US
Mailing Address - Phone:512-322-2030
Mailing Address - Fax:512-938-1016
Practice Address - Street 1:503 UHLAND RD
Practice Address - Street 2:TRLR 43
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-6680
Practice Address - Country:US
Practice Address - Phone:512-322-2030
Practice Address - Fax:512-938-1016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care