Provider Demographics
NPI:1043703358
Name:PURPLE HEARTS PRIMARY CARE SERVICES, PLLC
Entity Type:Organization
Organization Name:PURPLE HEARTS PRIMARY CARE SERVICES, PLLC
Other - Org Name:PURPLE HEARTS PRIMARY CARE SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:RAVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MODISETTE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C,PMHNP-BC
Authorized Official - Phone:817-969-4651
Mailing Address - Street 1:3901 ARLINGTON HIGHLANDS BLVD STE 281
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018-6036
Mailing Address - Country:US
Mailing Address - Phone:817-969-4651
Mailing Address - Fax:214-710-2188
Practice Address - Street 1:688 W PIONEER PKWY STE 120
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-4861
Practice Address - Country:US
Practice Address - Phone:817-969-4651
Practice Address - Fax:214-710-2188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-11
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137299261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX393575101Medicaid