Healthcare Provider Details

I. General information

NPI: 1114800133
Provider Name (Legal Business Name): PC IPA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 N CENTRAL EXPY, SUITE 150
RICHARDSON TX
75080
US

IV. Provider business mailing address

2929 N CENTRAL EXPY, SUITE 150
RICHARDSON TX
75080
US

V. Phone/Fax

Practice location:
  • Phone: 469-663-4321
  • Fax:
Mailing address:
  • Phone: 469-663-4321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JAKE FROST
Title or Position: PRESIDENT
Credential:
Phone: 469-663-4321