Provider Demographics
NPI:1114563376
Name:MYCOMMUNITYCENTER
Entity Type:Organization
Organization Name:MYCOMMUNITYCENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EVAH
Authorized Official - Middle Name:D
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-616-3413
Mailing Address - Street 1:ATTN.: MOHAMMED PARACHA
Mailing Address - Street 2:2808 BROOKSHIRE DRIVE
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092
Mailing Address - Country:US
Mailing Address - Phone:817-616-3413
Mailing Address - Fax:817-616-3388
Practice Address - Street 1:7100 BOULEVARD 26 STE 106
Practice Address - Street 2:
Practice Address - City:RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-8687
Practice Address - Country:US
Practice Address - Phone:817-616-3413
Practice Address - Fax:817-616-3388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty