Provider Demographics
NPI:1164982039
Name:XPRESS PROVIDER SERVICE PLLC
Entity Type:Organization
Organization Name:XPRESS PROVIDER SERVICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:TERAN CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:817-831-2012
Mailing Address - Street 1:2900 DENTON HWY STE A
Mailing Address - Street 2:
Mailing Address - City:HALTOM CITY
Mailing Address - State:TX
Mailing Address - Zip Code:76117-3763
Mailing Address - Country:US
Mailing Address - Phone:817-831-2012
Mailing Address - Fax:817-831-0134
Practice Address - Street 1:2900 DENTON HWY STE A
Practice Address - Street 2:
Practice Address - City:HALTOM CITY
Practice Address - State:TX
Practice Address - Zip Code:76117-3763
Practice Address - Country:US
Practice Address - Phone:817-831-2012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX308878301Medicaid