Provider Demographics
NPI:1548951718
Name:CLINICAS SIN FRONTERAS FORT WORTH INC
Entity type:Organization
Organization Name:CLINICAS SIN FRONTERAS FORT WORTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:
Authorized Official - Last Name:MATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-926-0298
Mailing Address - Street 1:2312 CONROE CT
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-2376
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 E SEMINARY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-2632
Practice Address - Country:US
Practice Address - Phone:817-439-9146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-17
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty