Provider Demographics
NPI:1174155477
Name:CHOICE SUPPORTIVE CARE TEAM INC.
Entity type:Organization
Organization Name:CHOICE SUPPORTIVE CARE TEAM INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-592-5670
Mailing Address - Street 1:120 E SOUTH TOWN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-4747
Mailing Address - Country:US
Mailing Address - Phone:903-592-5670
Mailing Address - Fax:903-209-2888
Practice Address - Street 1:120 E SOUTH TOWN DR STE 100
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-4747
Practice Address - Country:US
Practice Address - Phone:903-925-6705
Practice Address - Fax:903-209-2888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-05
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00654697OtherRAIL ROAD
TX1174155477OtherNPI
TXP00654697OtherRAIL ROAD
TX75-0818-167-048OtherTRICARE