Basic Information
| Provider Information | |||||||||
| NPI: | 1831270693 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEXIA PRINCIPAL HEALTHCARE LIMITD PARTNERSHIP | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PARKVIEW MEDICAL CLINIC AT TEAGUE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 POWELL CT | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153728500 | ||||||||
| FaxNumber: | 6153372857 | ||||||||
| Practice Location | |||||||||
| Address1: | HIGHWAY 84 AT 8TH AVE. | ||||||||
| Address2: | |||||||||
| City: | TEAGUE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547395090 | ||||||||
| FaxNumber: | 2547395666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 09/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | GRACEY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 6153728500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEXIA PRINCIPAL HEALTHCARE LIMITD PARTNERSHIP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 173417001 | 05 | TX | MEDICAID |