Provider Demographics
NPI:1124429675
Name:ABC PROVIDER DFW LLC
Entity type:Organization
Organization Name:ABC PROVIDER DFW LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FORBES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-353-8717
Mailing Address - Street 1:712 CYPRESS HILL DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-5047
Mailing Address - Country:US
Mailing Address - Phone:469-353-8717
Mailing Address - Fax:469-353-8785
Practice Address - Street 1:712 CYPRESS HILL DR
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-5047
Practice Address - Country:US
Practice Address - Phone:469-353-8717
Practice Address - Fax:469-353-8785
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ABC PROVIDER DFW LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-15
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX015102253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care