Healthcare Provider Details

I. General information

NPI: 1003621202
Provider Name (Legal Business Name): CARENCIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2025
Last Update Date: 02/13/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 W RANDOL MILL RD
ARLINGTON TX
76012-3113
US

IV. Provider business mailing address

PO BOX 121592
ARLINGTON TX
76012-1592
US

V. Phone/Fax

Practice location:
  • Phone: 682-478-5333
  • Fax: 682-499-7705
Mailing address:
  • Phone: 682-478-5333
  • Fax: 682-499-7705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JESSE TUCKER
Title or Position: OWNER/PROVIDER
Credential: APRN
Phone: 817-478-5333