MEDICARE: CLINICA GUADALUPE WALNUT HILL 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

General Provider Information

NPI Number	:	1174219802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICA GUADALUPE WALNUT HILL LLC

Provider Business Mailing Address
First Line	:	14951 DALLAS PKWY STE 190
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75254-6894
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2555 WALNUT HILL LN STE 110
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75229-5629
Country	:	US
Telephone Number	:	972-252-3700
Fax Number	:	972-252-3701

Authorized Official
Title or Position	:	OFFICER
Name	:	CINDY OLALDE
Credential	:
Telephone Number	:	214-240-1506

Provider Enumeration Date	:	04/14/2023
Last Update Date	:	04/14/2023

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