MEDICARE: TRIANGLE CLINIC 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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1609120757
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIANGLE CLINIC LLC

Provider Business Mailing Address
First Line	:	3128 SABA LN
Second Line	:
City	:	PORT NECHES
State	:	TX
Zip	:	77651-5422
Country	:	US
Telephone Number	:	409-724-1404
Fax Number	:	409-724-0171

Provider Business Practice Location Address
First Line	:	3128 SABA LN
Second Line	:
City	:	PORT NECHES
State	:	TX
Zip	:	77651-5422
Country	:	US
Telephone Number	:	409-724-1404
Fax Number	:	409-724-0171

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. EILEEN MARIE NGUYEN
Credential	:	MT,ASCP
Telephone Number	:	409-724-1404

Provider Enumeration Date	:	10/27/2012
Last Update Date	:	10/27/2012

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