Healthcare Provider Details

I. General information

NPI: 1043576218
Provider Name (Legal Business Name): 7872 INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 CLINIC DR
LONGVIEW TX
75605-5172
US

IV. Provider business mailing address

2400 SUGAR CREEK CIR
LONGVIEW TX
75605-2580
US

V. Phone/Fax

Practice location:
  • Phone: 903-212-3105
  • Fax:
Mailing address:
  • Phone: 214-334-6831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. RUPA PEDDIREDDY
Title or Position: PRESIDENT
Credential: M.D
Phone: 214-392-5974