Provider Demographics
NPI:1679191779
Name:ALICE PLACE HEALTH CARE SERVICES
Entity Type:Organization
Organization Name:ALICE PLACE HEALTH CARE SERVICES
Other - Org Name:ALICE PLACE MEDICAL CARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:DR
Authorized Official - First Name:MONNIE
Authorized Official - Middle Name:ESTHER
Authorized Official - Last Name:ADERETI
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:469-756-7021
Mailing Address - Street 1:2719 LA JOLLA BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-0299
Mailing Address - Country:US
Mailing Address - Phone:469-756-7021
Mailing Address - Fax:469-502-3622
Practice Address - Street 1:3333 WILLOUBY DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-6129
Practice Address - Country:US
Practice Address - Phone:615-810-5983
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-06
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1922498468Medicaid