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General NPI Number Information
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NPI Number | 1043351760
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Entity Type | Organization
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Legal Business Name | SOUTH POLK MEDICAL CLINIC LLC
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Dates
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Enumeration Date | 02/08/2007
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Last Update Date | 07/26/2011
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Provider Practice Location Address
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Address Line | 3436 S POLK ST
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City | DALLAS
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State | TX
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Zip | 75224-3804
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Country | US
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Telephone | 214-372-1051
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Fax | 214-372-9201
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Provider Business Mailing Address
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Address Line | 3436 S POLK ST
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City | DALLAS
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State | TX
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Zip | 75224-3804
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Country | US
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Telephone | 214-372-1051
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Fax | 214-372-9201
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Authorized Official
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Title or Position | VICE PRESIDENT OF BUSINESS AFFAIRS
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Name | MR. EL GRECO ROBERTS
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Credential |
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Telephone | 214-372-1051
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 578285
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License Number State | TX
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