Basic Information
| Provider Information | |||||||||
| NPI: | 1689089401 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CWIDA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4400 W UNIVERSITY BLVD | ||||||||
| Address2: | APT: 10306 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752093876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177295793 | ||||||||
| FaxNumber: | 8662926489 | ||||||||
| Practice Location | |||||||||
| Address1: | 15800 DOOLEY RD STE 170 | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750015712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9726612273 | ||||||||
| FaxNumber: | 8662926489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2014 | ||||||||
| LastUpdateDate: | 07/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | FOJTAEK | ||||||||
| AuthorizedOfficialFirstName: | MARVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9726612273 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0600X | 767459 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Gerontology | 363LG0600X | AP125351 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.