Provider Demographics
NPI:1992416259
Name:MISSION EAST DALLAS AND METROPLEX PROJECT, INC.
Entity type:Organization
Organization Name:MISSION EAST DALLAS AND METROPLEX PROJECT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:WILTRAUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-682-8917
Mailing Address - Street 1:4550 GUS THOMASSON RD STE 40
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-1758
Mailing Address - Country:US
Mailing Address - Phone:972-682-8917
Mailing Address - Fax:
Practice Address - Street 1:341 WHEATFIELD DR STE 190
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:TX
Practice Address - Zip Code:75182-4639
Practice Address - Country:US
Practice Address - Phone:972-682-8917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSION EAST DALLAS AND METROPLEX PROJECT, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)