Provider Demographics
NPI:1568455673
Name:LINDALE MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:LINDALE MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:R
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-882-3194
Mailing Address - Street 1:PO BOX 1509
Mailing Address - Street 2:
Mailing Address - City:LINDALE
Mailing Address - State:TX
Mailing Address - Zip Code:75771-1509
Mailing Address - Country:US
Mailing Address - Phone:903-882-3194
Mailing Address - Fax:903-882-7405
Practice Address - Street 1:206 W HUBBARD ST
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771-6215
Practice Address - Country:US
Practice Address - Phone:903-882-3164
Practice Address - Fax:903-882-7405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0424207Q00000X
TXH0425207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A66825Medicare UPIN
TX00G84LMedicare PIN
A66826Medicare UPIN
80M161Medicare ID - Type UnspecifiedDONNA HAND
80M162Medicare ID - Type UnspecifiedWENDELL HAND