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General NPI Number Information
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NPI Number | 1871910505
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Entity Type | Organization
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Legal Business Name | THRIVE LLC
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Dates
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Enumeration Date | 03/19/2014
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Last Update Date | 03/19/2014
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Provider Practice Location Address
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Address Line | 4020 OAK LAWN AVE
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City | DALLAS
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State | TX
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Zip | 75219-3134
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Country | US
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Telephone | 214-420-0100
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Fax | 214-420-0101
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Provider Business Mailing Address
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Address Line | 4020 OAK LAWN AVE
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City | DALLAS
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State | TX
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Zip | 75219-3134
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Country | US
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Telephone | 214-420-0100
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Fax | 214-420-0101
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Authorized Official
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Title or Position | OWNER
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Name | DR. CLINTON F HERZOG
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Credential | DDS
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Telephone | 214-420-0100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number | H4764
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License Number State | TX
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