MEDICARE: COLLIN HOUSE CALL PHYSICIAN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center
2	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1437871761
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLIN HOUSE CALL PHYSICIAN LLC

Provider Business Mailing Address
First Line	:	PO BOX 743842
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75374-3842
Country	:	US
Telephone Number	:	469-238-4774
Fax Number	:

Provider Business Practice Location Address
First Line	:	9550 FOREST LN STE 745
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-5905
Country	:	US
Telephone Number	:	469-238-4774
Fax Number	:

Authorized Official
Title or Position	:	MEMBER AND MANAGER
Name	:	HABTOM LEGESE TEWELDEBRAHAN
Credential	:	NP
Telephone Number	:	469-238-4774

Provider Enumeration Date	:	09/14/2022
Last Update Date	:	04/18/2026

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