Healthcare Provider Details

I. General information

NPI: 1982924239
Provider Name (Legal Business Name): PCA-C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 06/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8110 WESLEY ST SUITE 100
GREENVILLE TX
75402-3935
US

IV. Provider business mailing address

PO BOX 957
GREENVILLE TX
75403-0957
US

V. Phone/Fax

Practice location:
  • Phone: 903-408-7751
  • Fax: 903-408-7802
Mailing address:
  • Phone: 903-408-7751
  • Fax: 903-408-7802

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: DR. LINTON KOGER
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 903-408-7751