Healthcare Provider Details

I. General information

NPI: 1215486691
Provider Name (Legal Business Name): WICHITA FALLS HEART CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 06/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 9TH ST
WICHITA FALLS TX
76301-4133
US

IV. Provider business mailing address

2101 9TH ST
WICHITA FALLS TX
76301-4133
US

V. Phone/Fax

Practice location:
  • Phone: 940-766-3190
  • Fax: 940-687-1617
Mailing address:
  • Phone: 940-766-3190
  • Fax: 940-687-1617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDRE DESIRE
Title or Position: CHAIRMAN
Credential:
Phone: 940-687-5000