Provider Demographics
NPI:1023266871
Name:COMPREHENSIVE BREAST CARE CENTER OF TEXAS, INC
Entity type:Organization
Organization Name:COMPREHENSIVE BREAST CARE CENTER OF TEXAS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:POLFREMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-398-4110
Mailing Address - Street 1:8401 JACK FINNEY BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75402-3017
Mailing Address - Country:US
Mailing Address - Phone:866-613-5807
Mailing Address - Fax:770-237-4819
Practice Address - Street 1:4430 LAVON DR
Practice Address - Street 2:STE. 226
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-3000
Practice Address - Country:US
Practice Address - Phone:972-530-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-05
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX288599801Medicaid
TX288599801Medicaid