Provider Demographics
NPI:1780119263
Name:FASTPASS UCR, PLLC
Entity type:Organization
Organization Name:FASTPASS UCR, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:DE MOOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-320-9820
Mailing Address - Street 1:5300 TOWN AND COUNTRY BLVD STE 260
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-6913
Mailing Address - Country:US
Mailing Address - Phone:469-208-5297
Mailing Address - Fax:214-260-0707
Practice Address - Street 1:400 ENTERPRISE BLVD STE A120
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-4341
Practice Address - Country:US
Practice Address - Phone:361-529-9401
Practice Address - Fax:361-529-9402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00U9Z8OtherBCBSTX
TX378405002OtherCSHCN
TX378405001Medicaid