Basic Information
| Provider Information | |||||||||
| NPI: | 1780741660 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEXAS HEALTH CARE, P.L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 961205 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761611205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177408400 | ||||||||
| FaxNumber: | 8173783699 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 SANTA FE | ||||||||
| Address2: | #103 | ||||||||
| City: | WEATHERFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760865865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173398855 | ||||||||
| FaxNumber: | 8173398889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 09/30/2011 | ||||||||
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| AuthorizedOfficialLastName: | TATUM | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | C.E.O. | ||||||||
| AuthorizedOfficialTelephone: | 8177408400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 154920601 | 05 | TX | MEDICAID |