Provider Demographics
NPI:1952061913
Name:RESIDUAL HEALTH CENTER
Entity Type:Organization
Organization Name:RESIDUAL HEALTH CENTER
Other - Org Name:RESIDUAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENADJA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:HHP, RCP
Authorized Official - Phone:682-323-7661
Mailing Address - Street 1:1106 N HWY 360 STE 300
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-2511
Mailing Address - Country:US
Mailing Address - Phone:682-323-7661
Mailing Address - Fax:
Practice Address - Street 1:1106 N HWY 360 STE 300
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-2511
Practice Address - Country:US
Practice Address - Phone:682-323-7661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-17
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX16643395OtherHEALTH & WELLNESS