Provider Demographics
NPI:1285162610
Name:C3EDF1, LLC
Entity type:Organization
Organization Name:C3EDF1, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:DE MOOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-320-9820
Mailing Address - Street 1:5300 TOWN AND COUNTRY BLVD STE 260
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-6913
Mailing Address - Country:US
Mailing Address - Phone:469-208-5297
Mailing Address - Fax:214-260-0707
Practice Address - Street 1:2390 INNOVATION DR.
Practice Address - Street 2:SUITE 100
Practice Address - City:DFW AIRPORT
Practice Address - State:TX
Practice Address - Zip Code:75261-9428
Practice Address - Country:US
Practice Address - Phone:214-997-1940
Practice Address - Fax:214-997-1941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-30
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX160362261QE0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency CareGroup - Single Specialty