=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396568713
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STELLA MATTINA PRIMARY CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2024
-----------------------------------------------------
Last Update Date | 11/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12201 MERIT DR STE 300
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75251-3139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-942-3100
-----------------------------------------------------
Fax | 469-399-0355
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12377 MERIT DR STE 550
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75251-2224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-868-2990
-----------------------------------------------------
Fax | 469-399-0355
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REVENUE CYCLE MANAGER
-----------------------------------------------------
Name | DINA NORIEGA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-868-2990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------