1093235046 NPI number — INVICTA FAMILY HEALTHCARE CLINIC, PLLC

Table of content: (NPI 1093235046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093235046 NPI number — INVICTA FAMILY HEALTHCARE CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INVICTA FAMILY HEALTHCARE 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:
6
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:
1093235046
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
904 W. MOORE AVE.
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
FORNEY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75126-0228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-563-1475
Provider Business Mailing Address Fax Number:
972-524-5132

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
904 W MOORE AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TERRELL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75160-3004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-563-1475
Provider Business Practice Location Address Fax Number:
972-524-5132
Provider Enumeration Date:
06/21/2017

Additional Information

Authorized Official

Authorized Official Last Name:
IDEMUDIA
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
O
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
972-563-1475

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LG0600X , 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)





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