Provider Demographics
NPI:1093235046
Name:INVICTA FAMILY HEALTHCARE CLINIC, PLLC
Entity Type:Organization
Organization Name:INVICTA FAMILY HEALTHCARE CLINIC, PLLC
Other - Org Name:REGIONAL HEALTH CLINIC AT TERRELL, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:O
Authorized Official - Last Name:IDEMUDIA
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:972-563-1475
Mailing Address - Street 1:904 W. MOORE AVE.
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-0228
Mailing Address - Country:US
Mailing Address - Phone:972-563-1475
Mailing Address - Fax:972-524-5132
Practice Address - Street 1:904 W MOORE AVE STE B
Practice Address - Street 2:
Practice Address - City:TERRELL
Practice Address - State:TX
Practice Address - Zip Code:75160-3004
Practice Address - Country:US
Practice Address - Phone:972-563-1475
Practice Address - Fax:972-524-5132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 261QP2300X
TX363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care