Provider Demographics
NPI:1396422036
Name:IDT ENTERPRISE LLC
Entity type:Organization
Organization Name:IDT ENTERPRISE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TELEMA
Authorized Official - Middle Name:
Authorized Official - Last Name:NGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-201-7934
Mailing Address - Street 1:1106 CORDOVA ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3198
Mailing Address - Country:US
Mailing Address - Phone:682-201-7934
Mailing Address - Fax:
Practice Address - Street 1:1510 N HAMPTON RD STE 150
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-8324
Practice Address - Country:US
Practice Address - Phone:682-201-7934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-04
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Single Specialty