Provider Demographics
NPI:1427426295
Name:BOARDWALK PROVIDERS GROUP LLC
Entity type:Organization
Organization Name:BOARDWALK PROVIDERS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIMMERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-406-9911
Mailing Address - Street 1:6750 N MACARTHUR BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-2875
Mailing Address - Country:US
Mailing Address - Phone:972-406-9911
Mailing Address - Fax:972-406-9930
Practice Address - Street 1:6750 N MACARTHUR BLVD
Practice Address - Street 2:STE 100
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-2875
Practice Address - Country:US
Practice Address - Phone:972-406-9911
Practice Address - Fax:972-406-9930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty