Provider Demographics
NPI:1376371450
Name:DENEBOLA TR
Entity type:Organization
Organization Name:DENEBOLA TR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:MORRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-954-1583
Mailing Address - Street 1:15500 VOSS RD # 1079
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77498-4601
Mailing Address - Country:US
Mailing Address - Phone:866-954-1583
Mailing Address - Fax:
Practice Address - Street 1:2225 NE 14TH AVE
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305-2305
Practice Address - Country:US
Practice Address - Phone:763-843-4433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty