Provider Demographics
NPI:1649585456
Name:DALLAS FORT WORTH IVF LLC
Entity type:Organization
Organization Name:DALLAS FORT WORTH IVF LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHANTILIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-363-5965
Mailing Address - Street 1:5477 GLEN LAKES DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-0946
Mailing Address - Country:US
Mailing Address - Phone:214-363-5965
Mailing Address - Fax:214-363-0639
Practice Address - Street 1:5477 GLEN LAKES DR
Practice Address - Street 2:SUITE 201
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0946
Practice Address - Country:US
Practice Address - Phone:214-363-5965
Practice Address - Fax:214-363-0639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D1095599291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory