Healthcare Provider Details

I. General information

NPI: 1457916041
Provider Name (Legal Business Name): RESOURCE CENTER LGBTQ HEALTH & WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 REAGAN ST
DALLAS TX
75219-3403
US

IV. Provider business mailing address

5750 CEDAR SPRINGS RD
DALLAS TX
75235-6802
US

V. Phone/Fax

Practice location:
  • Phone: 214-540-4492
  • Fax: 214-261-2318
Mailing address:
  • Phone: 214-521-5124
  • Fax: 214-522-4604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MARISA ELLIOTT
Title or Position: COO
Credential:
Phone: 214-521-5124