Provider Demographics
NPI:1871986109
Name:CLINIC 21 OF TARRANT COUNTY, PLLC
Entity type:Organization
Organization Name:CLINIC 21 OF TARRANT COUNTY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:PACKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-493-4443
Mailing Address - Street 1:4535 DRESSLER RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2545
Mailing Address - Country:US
Mailing Address - Phone:330-493-4443
Mailing Address - Fax:330-451-4142
Practice Address - Street 1:431 E. STATE HIGHWAY 114 SUITE 120
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-4407
Practice Address - Country:US
Practice Address - Phone:817-251-3981
Practice Address - Fax:817-251-3245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-11
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7399370001Medicare NSC