Provider Demographics
NPI:1205448131
Name:CLYDIES PLACE
Entity type:Organization
Organization Name:CLYDIES PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:THURMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-855-0845
Mailing Address - Street 1:PO BOX 596
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:75686-0596
Mailing Address - Country:US
Mailing Address - Phone:903-855-0845
Mailing Address - Fax:903-855-0746
Practice Address - Street 1:424 HENDERSON ST
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:TX
Practice Address - Zip Code:75686-1118
Practice Address - Country:US
Practice Address - Phone:903-855-0845
Practice Address - Fax:903-855-0746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-21
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health