Provider Demographics
NPI:1114358413
Name:COPPELL CARE
Entity Type:Organization
Organization Name:COPPELL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MANOHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:VAJJA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-899-1911
Mailing Address - Street 1:651 N DENTON TAP RD SUITE 100
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019
Mailing Address - Country:US
Mailing Address - Phone:972-899-1911
Mailing Address - Fax:
Practice Address - Street 1:651 N DENTON TAP RD STE 100
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-2010
Practice Address - Country:US
Practice Address - Phone:214-886-8496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7714173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty