Basic Information
| Provider Information | |||||||||
| NPI: | 1467990630 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CEC LAKEWAY URGENT CARE PHYSICIANS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TEXAS COMPLETE URGENT CARE PHYSICIANS CROWLEY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 92152 | ||||||||
| Address2: | |||||||||
| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760920102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174210012 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1900 W. EVERMAN PARWAY | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761344326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174210012 | ||||||||
| FaxNumber: | 8174210036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2017 | ||||||||
| LastUpdateDate: | 10/22/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEIMAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | BRAXTON | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 8174210012 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | ESQ | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.