1033499967 NPI number — TEXAS ELITE HEALTH CLINIC, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033499967 NPI number — TEXAS ELITE HEALTH CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEXAS ELITE HEALTH CLINIC, LLC
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:
1033499967
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 116762
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARROLLTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75011-6762
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-402-9700
Provider Business Mailing Address Fax Number:
972-402-9706

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1304 VILLAGE CREEK DR
Provider Second Line Business Practice Location Address:
SUITE 300-B
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75093-4472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-402-9700
Provider Business Practice Location Address Fax Number:
972-402-9706
Provider Enumeration Date:
08/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
POWELL
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
FAMILY NURSE PRACTITIONER
Authorized Official Telephone Number:
972-402-9700

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  774439 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2971285-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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