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688 W Pioneer Pkwy Ste 120 Grand Prairie TX 75051-4861 | |
| (817) 969-4651 | |
| (214) 710-2188 |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Primary Care |
| Location | 688 W Pioneer Pkwy Ste 120, Grand Prairie, Texas |
| Authorized Official Name and Position | Raven Modisette (CEO) |
| Authorized Official Contact | 8179694651 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
3901 Arlington Highlands Blvd Ste 281 Arlington TX 76018-6036 Ph: (817) 969-4651 | 688 W Pioneer Pkwy Ste 120 Grand Prairie TX 75051-4861 Ph: (817) 969-4651 |
| NPI Number | 1043703358 |
|---|---|
| Provider Enumeration Date | 06/11/2018 |
| Last Update Date | 12/07/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1043703358 | NPI | - | NPPES |
| 393575101 | Medicaid | TX |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | AP137299 (Texas) | Primary |
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