Provider Demographics
NPI:1295271682
Name:DFW LICENSED ASSISTANT, LLC
Entity type:Organization
Organization Name:DFW LICENSED ASSISTANT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:CSFA
Authorized Official - Phone:817-851-5517
Mailing Address - Street 1:4 ROCKLAND CT
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5006
Mailing Address - Country:US
Mailing Address - Phone:817-851-5517
Mailing Address - Fax:817-756-7672
Practice Address - Street 1:4 ROCKLAND CT
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5006
Practice Address - Country:US
Practice Address - Phone:817-851-5517
Practice Address - Fax:817-756-7672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX132517246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Single Specialty