Provider Demographics
NPI:1215909098
Name:ROBBY LYNN FUGITT AND JERRY REVLAND
Entity type:Organization
Organization Name:ROBBY LYNN FUGITT AND JERRY REVLAND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBBY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FUGITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-350-2760
Mailing Address - Street 1:3562 FOREST LANE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7932
Mailing Address - Country:US
Mailing Address - Phone:214-350-2760
Mailing Address - Fax:214-350-2769
Practice Address - Street 1:3562 FOREST LANE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7932
Practice Address - Country:US
Practice Address - Phone:214-350-2760
Practice Address - Fax:214-350-2769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0862960001Medicare ID - Type Unspecified