MEDICARE: SOUTHERN SECTOR HEALTH INITIATIVE

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	261QC1500X	Community Health Clinic/Center

General Provider Information

NPI Number	:	1790382596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN SECTOR HEALTH INITIATIVE

Provider Business Mailing Address
First Line	:	4500 SPRING AVE STE 142
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75210-1350
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4500 SPRING AVE STE 142
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75210-1350
Country	:	US
Telephone Number	:	214-865-3060
Fax Number	:

Authorized Official
Title or Position	:	CEO/VP
Name	:	VENITA OWENS
Credential	:
Telephone Number	:	214-865-3099

Provider Enumeration Date	:	10/05/2020
Last Update Date	:	10/05/2020

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