Provider Demographics
NPI:1457742744
Name:DESOTO INJURY REHAB LLC
Entity Type:Organization
Organization Name:DESOTO INJURY REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-297-6575
Mailing Address - Street 1:509 N HAMPTON RD STE 100A
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-4970
Mailing Address - Country:US
Mailing Address - Phone:469-297-6575
Mailing Address - Fax:469-533-0307
Practice Address - Street 1:509 N HAMPTON RD STE 100A
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-4970
Practice Address - Country:US
Practice Address - Phone:469-297-6575
Practice Address - Fax:469-533-0307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0011366111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty