Provider Demographics
NPI:1386158640
Name:PORTABLE PICCLINE INSERTION
Entity type:Organization
Organization Name:PORTABLE PICCLINE INSERTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-566-4899
Mailing Address - Street 1:221 BUIE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76140-2931
Mailing Address - Country:US
Mailing Address - Phone:817-566-4899
Mailing Address - Fax:
Practice Address - Street 1:2304 OAK LN STE 205
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-8816
Practice Address - Country:US
Practice Address - Phone:972-201-4091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-24
Last Update Date:2017-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty