Provider Demographics
NPI:1659446409
Name:PROVIDENT MEDICAL CENTER
Entity Type:Organization
Organization Name:PROVIDENT MEDICAL CENTER
Other - Org Name:CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:214-948-7783
Mailing Address - Street 1:831 SR L THORNTON FWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-2905
Mailing Address - Country:US
Mailing Address - Phone:214-948-7783
Mailing Address - Fax:214-948-7793
Practice Address - Street 1:831 SR L THORNTON FWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-2905
Practice Address - Country:US
Practice Address - Phone:214-948-7783
Practice Address - Fax:214-948-7793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1172261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center