Provider Demographics
NPI:1588144893
Name:SOUTHLAKE DOCTORS EXPRESS, PA PSC
Entity type:Organization
Organization Name:SOUTHLAKE DOCTORS EXPRESS, PA PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:RAINS
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:817-488-9922
Mailing Address - Street 1:2315 E SOUTHLAKE BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6684
Mailing Address - Country:US
Mailing Address - Phone:817-488-9922
Mailing Address - Fax:817-488-8917
Practice Address - Street 1:325 CENTRAL EXPY S
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-2786
Practice Address - Country:US
Practice Address - Phone:469-640-4232
Practice Address - Fax:469-854-6453
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHLAKE DOCTORS EXPRESS, PA PSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-16
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty