Healthcare Provider Details

I. General information

NPI: 1871929737
Provider Name (Legal Business Name): LAKE TEXOMA HEALTH CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2013
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81750 N STATE HWY 289 SUITE 101
POTTSBORO TX
75076
US

IV. Provider business mailing address

81750 N STATE HWY 289 SUITE 101
POTTSBORO TX
75076
US

V. Phone/Fax

Practice location:
  • Phone: 903-357-5014
  • Fax: 866-823-8694
Mailing address:
  • Phone: 903-357-5014
  • Fax: 866-823-8694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number583252
License Number StateTX

VIII. Authorized Official

Name: MS. DEBORAH LYNN BURCHFIELD
Title or Position: OWNER
Credential: FNP-C
Phone: 903-357-5014