Provider Demographics
NPI:1982730461
Name:TEXAS KNEE & SPORTS MEDICINE CENTER, PA
Entity Type:Organization
Organization Name:TEXAS KNEE & SPORTS MEDICINE CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-394-0118
Mailing Address - Street 1:4323 N JOSEY LANE SUITE 307
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4630
Mailing Address - Country:US
Mailing Address - Phone:972-394-0118
Mailing Address - Fax:972-394-1058
Practice Address - Street 1:4323 N JOSEY LANE SUITE 307
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4630
Practice Address - Country:US
Practice Address - Phone:972-394-0118
Practice Address - Fax:972-394-1058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9619207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC17436Medicare UPIN
TX4878330001Medicare NSC
TX00F74EMedicare PIN