Basic Information
| Provider Information | |||||||||
| NPI: | 1720412141 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TYLER FAMILY CIRCLE OF CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844273 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035359041 | ||||||||
| FaxNumber: | 9035319490 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 E HOUSTON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035359041 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2013 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | SWAN | ||||||||
| AuthorizedOfficialFirstName: | LORETTA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BOARD CHAIRPERSON | ||||||||
| AuthorizedOfficialTelephone: | 9035101113 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 311152804 | 05 | TX | MEDICAID |