=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740972777
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLINICA GUADALUPE FORT WORTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2023
-----------------------------------------------------
Last Update Date | 05/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2566 GUS THOMASSON RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75228-3017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-399-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2566 GUS THOMASSON RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75228-3017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-399-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE ADMINSTRATOR
-----------------------------------------------------
Name | CYNTHIA OLALDE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-240-1506
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------