MEDICARE: CLINICA INTEGRAL FAMILIA SANA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1043780513	OTHER	TX	NURSE PRACTIONER

General Provider Information

NPI Number	:	1134833650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICA INTEGRAL FAMILIA SANA LLC

Provider Business Mailing Address
First Line	:	2950 W CAMP WISDOM RD STE 100
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-4461
Country	:	US
Telephone Number	:	214-235-0114
Fax Number	:	214-677-0043

Provider Business Practice Location Address
First Line	:	2950 W CAMP WISDOM RD STE 100
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-4461
Country	:	US
Telephone Number	:	214-235-0114
Fax Number	:	214-677-0043

Authorized Official
Title or Position	:	MANAGER
Name	:	SANDRA SABALLET
Credential	:
Telephone Number	:	786-327-8992

Provider Enumeration Date	:	01/09/2023
Last Update Date	:	01/11/2023

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