SOUTH LOOP 12 MEDICAL CLINIC LLC NPI 1417034745

NPI Information

SOUTH LOOP 12 MEDICAL CLINIC LLC is a family nurse practitioner in Dallas, TX. SOUTH LOOP 12 MEDICAL CLINIC LLC NPI is 1417034745. The provider is registered as an organization entity type and is a single specialty group.

The provider's business location address is:

3232 GREAT TRINITY FOREST WAY
STE. 102
DALLAS, TX
ZIP 75216-732
Phone: (214) 398-4157
Fax: (214) 398-4326

The provider's authorized official is Connie Frances Nellum .
The authorized official title is Family Nurse Pactitione Certified and has the following contact phone number (214) 398-4157.

The CLIA number assigned to this NPI record is 45D1022305 - community clinic with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 11/1/2006 and was last updated on 10/9/2014.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

All materials and services on this site are provided on an "as is" and "as available" basis without warranty of any kind. The NPI record is maintained by the National Plan & Provider Enumeration System (NPPES) and anyone may request this information and other NPPES health care provider data from HHS under The Freedom of Information Act (FOIA), Title 5 of the United States Code, section 552. To update the NPI records please contact the NPPES.