Provider Demographics
NPI:1912011602
Name:DARLA JO HANSON
Entity Type:Organization
Organization Name:DARLA JO HANSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARLA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:CMF
Authorized Official - Phone:432-366-1158
Mailing Address - Street 1:3302 COUNTY ROAD O
Mailing Address - Street 2:
Mailing Address - City:ACKERLY
Mailing Address - State:TX
Mailing Address - Zip Code:79713-4038
Mailing Address - Country:US
Mailing Address - Phone:432-366-1158
Mailing Address - Fax:432-366-1158
Practice Address - Street 1:4101 E 42ND ST
Practice Address - Street 2:MUSIC CITY MALL #95
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-7239
Practice Address - Country:US
Practice Address - Phone:432-366-1158
Practice Address - Fax:432-366-1158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0107997-01Medicaid
TX103263100OtherFIRST CARE
TX530030OtherBC/BS
TX1180730001Medicare NSC