Provider Demographics
NPI:1922355775
Name:CAPTIVE MEDICAL, PLLC
Entity Type:Organization
Organization Name:CAPTIVE MEDICAL, PLLC
Other - Org Name:CAPTIVE MEDICAL, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:TINLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-916-4685
Mailing Address - Street 1:649 NE ALSBURY BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-2660
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:649 NE ALSBURY BLVD
Practice Address - Street 2:STE 105
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-2660
Practice Address - Country:US
Practice Address - Phone:817-426-1212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-11
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty