MEDICARE: 22250 BULVERDE CEC FOSSIL CREEK 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	261QE0002X	Emergency Care Clinic/Center

General Provider Information

NPI Number	:	1740603422
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	22250 BULVERDE CEC FOSSIL CREEK LLC

Provider Business Mailing Address
First Line	:	PO BOX 93059
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-1059
Country	:	US
Telephone Number	:	817-421-0034
Fax Number	:	817-421-0036

Provider Business Practice Location Address
First Line	:	22250 BULVERDE RD
Second Line	:	120
City	:	SAN ANTONIO
State	:	TX
Zip	:	78261-3084
Country	:	US
Telephone Number	:	817-421-0034
Fax Number	:	817-421-0036

Authorized Official
Title or Position	:	COO
Name	:	JULIE RADLEY
Credential	:
Telephone Number	:	713-591-2256

Provider Enumeration Date	:	01/30/2014
Last Update Date	:	02/10/2022

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