=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427312859
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICHARDSON WALK IN CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2012
-----------------------------------------------------
Last Update Date | 11/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 930 E CAMPBELL RD SUITE 106
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75081-2047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-545-1694
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 930 E CAMPBELL RD SUITE 106
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75081-2047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-545-1694
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MICHAEL JEFFREY JENKS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 956-545-1694
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | L1083
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------