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General NPI Number Information
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NPI Number | 1306898374
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Entity Type | Organization
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Legal Business Name | TEXOMA KIDNEY CARE, P.A.
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Dates
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Enumeration Date | 05/17/2006
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Last Update Date | 03/12/2008
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Provider Practice Location Address
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Address Line | 201 MEMORIAL DR SUITE 201
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City | DENISON
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State | TX
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Zip | 75020-2026
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Country | US
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Telephone | 903-463-5057
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Fax | 903-463-7661
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Provider Business Mailing Address
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Address Line | 201 MEMORIAL DR SUITE 201
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City | DENISON
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State | TX
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Zip | 75020-2026
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Country | US
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Telephone | 903-463-5057
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Fax | 903-463-7661
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Authorized Official
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Title or Position | PRESIDENT
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Name | GLEN ROBERT WILLIE
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Credential | M.D.
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Telephone | 903-463-5057
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | G0858
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License Number State | TX
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