Provider Demographics
NPI:1306372917
Name:LECELT, INC
Entity Type:Organization
Organization Name:LECELT, INC
Other - Org Name:HENRIKSON PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HENRIKSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:325-703-6670
Mailing Address - Street 1:3371 KNICKERBOCKER RD
Mailing Address - Street 2:# 236
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6814
Mailing Address - Country:US
Mailing Address - Phone:325-703-6670
Mailing Address - Fax:325-703-6672
Practice Address - Street 1:2133 OFFICE PARK DR STE A
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6803
Practice Address - Country:US
Practice Address - Phone:325-703-6670
Practice Address - Fax:325-703-6672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164744807Medicaid
TX164744807Medicaid