Basic Information
| Provider Information | |||||||||
| NPI: | 1548861461 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DELOSSANTOS | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | JAMES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1308 | ||||||||
| Address2: | |||||||||
| City: | COPPELL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750191300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146863223 | ||||||||
| FaxNumber: | 9727242495 | ||||||||
| Practice Location | |||||||||
| Address1: | 12413 JUDSON RD STE 260 | ||||||||
| Address2: | |||||||||
| City: | LIVE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782333262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106567953 | ||||||||
| FaxNumber: | 2106567957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2020 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1327860 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.