Provider Demographics
NPI:1700543873
Name:CIVITAS CLINICAL SERVICES LLC
Entity Type:Organization
Organization Name:CIVITAS CLINICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SELBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-220-5859
Mailing Address - Street 1:6503 AUGUSTA NATIONAL DR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210
Mailing Address - Country:US
Mailing Address - Phone:940-220-5859
Mailing Address - Fax:940-898-1986
Practice Address - Street 1:4400 TEASLEY LN # 400
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-4650
Practice Address - Country:US
Practice Address - Phone:940-220-5859
Practice Address - Fax:940-220-5859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty