Provider Demographics
NPI:1740618206
Name:ECCARE PROFESSIONAL ASSOCIATION OF TEXAS P.A.
Entity Type:Organization
Organization Name:ECCARE PROFESSIONAL ASSOCIATION OF TEXAS P.A.
Other - Org Name:ECCARE HEALTH CENTERS OF TEXAS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:P
Authorized Official - Last Name:ENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-659-1234
Mailing Address - Street 1:PO BOX 153068
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75015-3068
Mailing Address - Country:US
Mailing Address - Phone:972-659-1234
Mailing Address - Fax:972-827-0195
Practice Address - Street 1:561 N GRAHAM ST
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-3548
Practice Address - Country:US
Practice Address - Phone:254-434-6400
Practice Address - Fax:254-965-6505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-21
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX801865115261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine