Provider Demographics
NPI:1164790572
Name:TCG CLINIC, LLC
Entity Type:Organization
Organization Name:TCG CLINIC, LLC
Other - Org Name:VITALCARING GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSE & CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-787-7609
Mailing Address - Street 1:9846 HWY 31 E
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75705-2329
Mailing Address - Country:US
Mailing Address - Phone:903-787-7609
Mailing Address - Fax:
Practice Address - Street 1:11301 FALLBROOK DR STE 220
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-4270
Practice Address - Country:US
Practice Address - Phone:713-500-0000
Practice Address - Fax:713-500-0050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX677209251E00000X, 251E00000X
TX655560000261QR0400X
TX552570000261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127339303Medicaid
TX677209OtherMEDICARE
TX127339306Medicaid