Provider Demographics
NPI:1639844954
Name:IMMACULATE CONCEPTION HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:IMMACULATE CONCEPTION HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAGRUTI
Authorized Official - Middle Name:
Authorized Official - Last Name:RAJ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-933-5223
Mailing Address - Street 1:2105 W SPRING CREEK PKWY STE 320
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75023-4566
Mailing Address - Country:US
Mailing Address - Phone:423-933-5223
Mailing Address - Fax:682-270-0116
Practice Address - Street 1:2105 W SPRING CREEK PKWY STE 320
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75023-4566
Practice Address - Country:US
Practice Address - Phone:423-933-5223
Practice Address - Fax:682-270-0116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-09
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty