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General NPI Number Information
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NPI Number | 1295337723
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Entity Type | Organization
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Legal Business Name | MDTELA
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Dates
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Enumeration Date | 11/10/2020
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Last Update Date | 11/10/2020
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Provider Practice Location Address
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Address Line | 160 SEPTEMBER DR
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City | STREETMAN
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State | TX
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Zip | 75859-3261
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Country | US
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Telephone | 833-463-8352
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 946
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City | ELKHART
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State | TX
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Zip | 75839-0946
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Country | US
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Telephone | 931-628-9210
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | KIMBERLY TATUM
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Credential | OWNER
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Telephone | 931-628-9210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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