Provider Demographics
NPI:1952702730
Name:GREATER DALLAS HEALTHCARE CORPORATION
Entity Type:Organization
Organization Name:GREATER DALLAS HEALTHCARE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:
Authorized Official - First Name:LES
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDKNOP
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-771-9081
Mailing Address - Street 1:2075 PONCHARTRAIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-6541
Mailing Address - Country:US
Mailing Address - Phone:214-264-9060
Mailing Address - Fax:
Practice Address - Street 1:1005 W RALPH HALL PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-6658
Practice Address - Country:US
Practice Address - Phone:972-771-9081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126278363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP126278OtherFNP