Healthcare Provider Details

I. General information

NPI: 1497123772
Provider Name (Legal Business Name): TEXOMA PRIMARY CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2015
Last Update Date: 09/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 KELL BLVD SUITE 500
WICHITA FALLS TX
76310-1612
US

IV. Provider business mailing address

5500 KELL BLVD SUITE 500
WICHITA FALLS TX
76310-1612
US

V. Phone/Fax

Practice location:
  • Phone: 940-264-2273
  • Fax:
Mailing address:
  • Phone: 940-264-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JERRY K MYERS
Title or Position: CEO
Credential: M.D.
Phone: 940-696-7518