Basic Information
| Provider Information | |||||||||
| NPI: | 1790110872 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ZL DALLAS SPINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 41 | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473080041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652840493 | ||||||||
| FaxNumber: | 7652842434 | ||||||||
| Practice Location | |||||||||
| Address1: | 17051 DALLAS PKWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750017105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148883900 | ||||||||
| FaxNumber: | 2148883901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2013 | ||||||||
| LastUpdateDate: | 10/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | ZABLOS | ||||||||
| AuthorizedOfficialFirstName: | PABLO | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER / DIRECTOR / PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2148883900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00C3600 | 01 | TX | BCBS ID NUMBER | OTHER |