Provider Demographics
NPI:1316079734
Name:ESA
Entity type:Organization
Organization Name:ESA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:EAMES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:254-694-5092
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146-8108
Mailing Address - Country:US
Mailing Address - Phone:254-694-5092
Mailing Address - Fax:254-694-7039
Practice Address - Street 1:508 WOODSTREAM PL
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-5874
Practice Address - Country:US
Practice Address - Phone:254-694-5092
Practice Address - Fax:254-694-7039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080347001Medicaid
TX0030BHMedicare ID - Type UnspecifiedMEDICARE