Basic Information
| Provider Information | |||||||||
| NPI: | 1427229947 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEXIA PRINCIPAL HEALTHCARE LIMITED PARTNERSHIP | ||||||||
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| OtherOrganizationName: | PARKVIEW REGIONAL MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 POWELL CT | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153728500 | ||||||||
| FaxNumber: | 6153728572 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 S BONHAM ST | ||||||||
| Address2: | |||||||||
| City: | MEXIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 766673603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2545625332 | ||||||||
| FaxNumber: | 2545622331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2008 | ||||||||
| LastUpdateDate: | 09/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | GRACEY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 6153728500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0068CK | 01 | BCBS OF TEXAS | OTHER |