South Loop 12 Medical Clinic LLC

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

528675 Issued in TX

Legal business name

SOUTH LOOP 12 MEDICAL CLINIC LLC

Practice address

3232 Great Trinity Forest Way
Ste. 102
Dallas, TX 75216-7732

Phone

(214) 398-4157

Fax

(214) 398-4326

NPI assigned

Nov 1, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ms. Connie Frances Nellum, MS, APRN-CNPI 1184830473

Title

Family Nurse Pactitione Certified

Phone

(214) 398-4157

Specialties & licenses 1

Addresses

Other identifiers 4

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Connie Nellum, NURSE PRACTITIONER

  • Family Nurse Practitioner
  • Mesquite, TX
  • NPI 1184830473
  Medicare reassignment Authorized official
• Adam L. Bank, PHD

  • Clinical Psychologist
  • Minneapolis, MN
  • NPI 1417995283
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1162339200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1412812800000",
    "number": "1417034745",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3232 GREAT TRINITY FOREST WAY",
            "address_2": "STE. 102",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752167732",
            "telephone_number": "214-398-4157",
            "fax_number": "214-398-4326"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3232 GREAT TRINITY FOREST WAY",
            "address_2": "STE. 102",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752167732",
            "telephone_number": "214-398-4157",
            "fax_number": "214-398-4326"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH LOOP 12 MEDICAL CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-01",
        "last_updated": "2014-10-09",
        "status": "A",
        "authorized_official_last_name": "NELLUM",
        "authorized_official_first_name": "CONNIE",
        "authorized_official_middle_name": "FRANCES",
        "authorized_official_title_or_position": "FAMILY NURSE PACTITIONE CERTIFIED",
        "authorized_official_telephone_number": "214-398-4157",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "MS, APRN-C"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": "TX",
            "license": "528675",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "018919303",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FIRST HEALTH PROVIDER ID",
            "identifier": "5608640",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA PROVIDER ID#",
            "identifier": "7438197",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBC PROVIDER ID#",
            "identifier": "8N8001",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Family Nurse Practitioner in Dallas, TX
• Providers in Dallas, TX by specialty
• Family Nurse Practitioner in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 9, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.