Basic Information
| Provider Information | |||||||||
| NPI: | 1740780956 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PSN FW HOLDCO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 ENCHANTED WAY SUITE 100 | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6822235552 | ||||||||
| FaxNumber: | 6822235560 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 HASKELL STREET | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179458000 | ||||||||
| FaxNumber: | 8179459679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2018 | ||||||||
| LastUpdateDate: | 02/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | FOWLER | ||||||||
| AuthorizedOfficialFirstName: | JORDAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9172166285 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.