=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588266647
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONNECT HEALTH CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2020
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1108 W PIONEER PKWY STE 200
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76013-7627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-252-4051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1108 W PIONEER PKWY STE 200
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76013-7627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BARACK OTIENO
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 817-808-7230
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------