Provider Demographics
NPI:1902401383
Name:IDEA TO GROW, LLC
Entity Type:Organization
Organization Name:IDEA TO GROW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-612-4531
Mailing Address - Street 1:1050 MAYFIELD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-6043
Mailing Address - Country:US
Mailing Address - Phone:561-275-2020
Mailing Address - Fax:561-828-8367
Practice Address - Street 1:3940 SAINT FRANCIS AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-6161
Practice Address - Country:US
Practice Address - Phone:561-275-2020
Practice Address - Fax:561-828-8367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear SupplierGroup - Single Specialty