Provider Demographics
NPI:1588775381
Name:TEXAS TECH UNIVERSITY HEALTH SERVICES CENTER-AMARILLO
Entity type:Organization
Organization Name:TEXAS TECH UNIVERSITY HEALTH SERVICES CENTER-AMARILLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:806-354-5495
Mailing Address - Street 1:1400 WALLACE BLVD
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106
Mailing Address - Country:US
Mailing Address - Phone:806-354-5585
Mailing Address - Fax:806-356-4673
Practice Address - Street 1:206 NE 7TH
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79101
Practice Address - Country:US
Practice Address - Phone:806-374-9964
Practice Address - Fax:806-374-2945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty