Healthcare Provider Details

I. General information

NPI: 1528009453
Provider Name (Legal Business Name): TGLP, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 MOORES LN SUITE B
TEXARKANA TX
75503-4610
US

IV. Provider business mailing address

1920 MOORES LN SUITE B
TEXARKANA TX
75503-4610
US

V. Phone/Fax

Practice location:
  • Phone: 903-791-8657
  • Fax: 903-791-8650
Mailing address:
  • Phone: 903-791-8657
  • Fax: 903-791-8650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number008336
License Number StateTX

VIII. Authorized Official

Name: MR. RANDY H POWELL
Title or Position: ADMINISTRATOR
Credential:
Phone: 903-792-8030