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General NPI Number Information
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NPI Number | 1700543873
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Entity Type | Organization
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Legal Business Name | CIVITAS CLINICAL SERVICES LLC
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Dates
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Enumeration Date | 11/23/2021
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Last Update Date | 11/23/2021
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Provider Practice Location Address
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Address Line | 4400 TEASLEY LN # 400
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City | DENTON
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State | TX
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Zip | 76210-4650
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Country | US
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Telephone | 940-220-5859
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Fax | 940-220-5859
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Provider Business Mailing Address
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Address Line | 6503 AUGUSTA NATIONAL DR
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City | DENTON
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State | TX
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Zip | 76210
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Country | US
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Telephone | 940-220-5859
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Fax | 940-898-1986
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Authorized Official
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Title or Position | OWNER/AUTHORIZED OFFICIAL
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Name | KELLY SELBY
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Credential |
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Telephone | 940-220-5859
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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