Provider Demographics
NPI:1992223085
Name:2017 FWUC MEDICAL PROFESSIONALS PLLC
Entity Type:Organization
Organization Name:2017 FWUC MEDICAL PROFESSIONALS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BRAXTON
Authorized Official - Last Name:NEIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-421-0034
Mailing Address - Street 1:920 S KIMBALL AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-9016
Mailing Address - Country:US
Mailing Address - Phone:817-527-3403
Mailing Address - Fax:
Practice Address - Street 1:601 NORTHWEST PKWY STE C
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-2930
Practice Address - Country:US
Practice Address - Phone:817-270-0777
Practice Address - Fax:817-421-0036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty