1164790572 NPI number — TCG 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 1164790572 NPI number — TCG CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TCG 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:
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:
1164790572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9846 HWY 31 E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75705-2329
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-787-7609
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11301 FALLBROOK DR STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77065-4270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-500-0000
Provider Business Practice Location Address Fax Number:
713-500-0050
Provider Enumeration Date:
12/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
ANGIE
Authorized Official Middle Name:
Authorized Official Title or Position:
LICENSE & CREDENTIALING
Authorized Official Telephone Number:
903-787-7609

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  677209 , 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: 127339303 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 677209 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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