Basic Information
| Provider Information | |||||||||
| NPI: | 1588398127 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRISTUS TRINITY CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1424 E FRONT ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035954144 | ||||||||
| FaxNumber: | 9035699974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2022 | ||||||||
| LastUpdateDate: | 07/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | KARL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, CFO | ||||||||
| AuthorizedOfficialTelephone: | 4692822611 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA, MPA | ||||||||
| NPICertificationDate: | 07/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | TX | MEDICAID |