Healthcare Provider Details

I. General information

NPI: 1316633043
Provider Name (Legal Business Name): CLINICA GUADALUPE GRAND PLAZA,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2023
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 SOUTH FWY STE 15
FORT WORTH TX
76115-1423
US

IV. Provider business mailing address

14951 DALLAS PKWY STE 190
DALLAS TX
75254-6894
US

V. Phone/Fax

Practice location:
  • Phone: 469-931-2538
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: CINDY OLALDE
Title or Position: OFFICER
Credential:
Phone: 214-240-1506