Provider Demographics
NPI:1942371687
Name:ELITE HEALTHCARE OF MANSFIELD
Entity Type:Organization
Organization Name:ELITE HEALTHCARE OF MANSFIELD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-453-5001
Mailing Address - Street 1:1600 HIGHWAY 287 N
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8853
Mailing Address - Country:US
Mailing Address - Phone:817-453-5001
Mailing Address - Fax:
Practice Address - Street 1:1600 HIGHWAY 287 N
Practice Address - Street 2:SUITE 104
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-8853
Practice Address - Country:US
Practice Address - Phone:817-453-5001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0040EGOtherBLUE CROSS BLUE SHIELD TX
TX0040EGOtherBLUE CROSS BLUE SHIELD TX