1013568914 NPI number — FELIZ FAMILY MEDICAL CLINIC PLLC

Table of content: (NPI 1013568914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013568914 NPI number — FELIZ FAMILY MEDICAL CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FELIZ FAMILY MEDICAL CLINIC PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013568914
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 DEER CREEK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNNYVALE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75182-3204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-965-9402
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3109 6TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76110-3800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-923-7055
Provider Business Practice Location Address Fax Number:
817-923-7902
Provider Enumeration Date:
09/23/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GEORGE
Authorized Official First Name:
SEEMA
Authorized Official Middle Name:
MOTTACKAL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
972-965-9402

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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