Provider Demographics
NPI:1205962727
Name:MINIRTH CLINIC PA
Entity type:Organization
Organization Name:MINIRTH CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:GAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-669-1733
Mailing Address - Street 1:1200 EAST COLLINS BLVD
Mailing Address - Street 2:SUITE #300
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081
Mailing Address - Country:US
Mailing Address - Phone:972-669-1733
Mailing Address - Fax:972-669-1403
Practice Address - Street 1:1200 EAST COLLINS BLVD
Practice Address - Street 2:SUITE #300
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081
Practice Address - Country:US
Practice Address - Phone:972-669-1733
Practice Address - Fax:972-669-1403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty