=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649085952
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TC AMARILLO 1 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2025
-----------------------------------------------------
Last Update Date | 06/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 S BLISS AVE STE 2
-----------------------------------------------------
City | DUMAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79029-4434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-421-0425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 S BLISS AVE STE 2
-----------------------------------------------------
City | DUMAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79029-4434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JERRED HURST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 806-421-0425
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------