Healthcare Provider Details

I. General information

NPI: 1700543873
Provider Name (Legal Business Name): CIVITAS CLINICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2021
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 TEASLEY LN # 400
DENTON TX
76210-4650
US

IV. Provider business mailing address

6503 AUGUSTA NATIONAL DR
DENTON TX
76210
US

V. Phone/Fax

Practice location:
  • Phone: 940-220-5859
  • Fax: 940-220-5859
Mailing address:
  • Phone: 940-220-5859
  • Fax: 940-898-1986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLY SELBY
Title or Position: OWNER/AUTHORIZED OFFICIAL
Credential:
Phone: 940-220-5859