Provider Demographics
NPI:1700812419
Name:TCG CLINIC, LLC
Entity type:Organization
Organization Name:TCG CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOONCE
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:713-383-2100
Mailing Address - Street 1:9220 KIRBY DR
Mailing Address - Street 2:1000
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-2500
Mailing Address - Country:US
Mailing Address - Phone:713-383-2100
Mailing Address - Fax:713-383-2114
Practice Address - Street 1:9220 KIRBY DR
Practice Address - Street 2:1000
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2500
Practice Address - Country:US
Practice Address - Phone:713-383-2100
Practice Address - Fax:713-383-2114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QH0700X
TX261QP2000X, 261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0008NNOtherBCBS OF TEXAS