=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134313083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTUS TRINITY CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2007
-----------------------------------------------------
Last Update Date | 01/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18780 INTERSTATE 20
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75103-3593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-567-4841
-----------------------------------------------------
Fax | 903-567-2818
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 846098
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75284-6098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-324-6400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | JOHN CHRISTOPHER GLENNEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-606-4445
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------