Provider Demographics
NPI:1639367329
Name:TCSD CLINIC LLC
Entity Type:Organization
Organization Name:TCSD CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CONTRACTING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHELLI
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-285-4914
Mailing Address - Street 1:PO BOX 5576
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-5576
Mailing Address - Country:US
Mailing Address - Phone:405-285-4914
Mailing Address - Fax:405-285-7127
Practice Address - Street 1:3120 W SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6783
Practice Address - Country:US
Practice Address - Phone:817-741-4521
Practice Address - Fax:817-741-4279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic