=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033499967
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEXAS ELITE HEALTH CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2011
-----------------------------------------------------
Last Update Date | 09/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1304 VILLAGE CREEK DR SUITE 300-B
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-4472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-402-9700
-----------------------------------------------------
Fax | 972-402-9706
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 116762
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75011-6762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-402-9700
-----------------------------------------------------
Fax | 972-402-9706
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FAMILY NURSE PRACTITIONER
-----------------------------------------------------
Name | MS. JULIE KAY POWELL
-----------------------------------------------------
Credential | RN, MSN, FNP
-----------------------------------------------------
Telephone | 972-402-9700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 774439
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------