Provider Demographics
NPI:1316256563
Name:TEXAS ENT CENTER, P A
Entity type:Organization
Organization Name:TEXAS ENT CENTER, P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:WALDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-431-7985
Mailing Address - Street 1:4601 HERITAGE TRACE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6443
Mailing Address - Country:US
Mailing Address - Phone:817-431-7985
Mailing Address - Fax:817-431-5031
Practice Address - Street 1:4601 HERITAGE TRACE PARKWAY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244
Practice Address - Country:US
Practice Address - Phone:817-431-7985
Practice Address - Fax:817-431-5031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6768207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR105419Medicare UPIN