Executive De-Tails – Contractor, NPI 1629134440
Contractor
Main info
Profile Insights
NPPES metrics only — not quality of care.
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Provider Addresses for Executive De-Tails
2952, Celian Drive, Lake Port Village, Mirabella Village, Grand Prairie, Tarrant County, Texas, 75052, United States
GRAND PRAIRIE, TX 750528737
Phone:
Mailing address matches the actual address.
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
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Medicare Enrollment & Revalidation
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Educational use only—not medical, billing, or legal advice.
No Medicare enrollment or revalidation data available for this provider in our database.
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Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
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No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 75052)
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