Provider Demographics
NPI:1083814966
Name:MANUEL GRIEGO JR DO PA
Entity Type:Organization
Organization Name:MANUEL GRIEGO JR DO PA
Other - Org Name:GRIEGO FAMILY MEDICAL CENTRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIEGO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:214-580-7277
Mailing Address - Street 1:1412 MAIN STREET
Mailing Address - Street 2:SUITE 905
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75202
Mailing Address - Country:US
Mailing Address - Phone:214-580-7277
Mailing Address - Fax:
Practice Address - Street 1:2701 S HAMPTON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224-2367
Practice Address - Country:US
Practice Address - Phone:214-330-9221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000HL68Medicaid
TX0026CCMedicare PIN
TXP000HL68Medicaid