Provider Demographics
NPI:1407566177
Name:CLINICA LA VIRGEN DE GUADALUPE INC
Entity Type:Organization
Organization Name:CLINICA LA VIRGEN DE GUADALUPE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:OLALDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-240-1506
Mailing Address - Street 1:14951 DALLAS PKWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-7892
Mailing Address - Country:US
Mailing Address - Phone:817-728-9616
Mailing Address - Fax:
Practice Address - Street 1:1303 N BEACH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111-6613
Practice Address - Country:US
Practice Address - Phone:682-385-0002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty