SOUTH LOOP 12 MEDICAL CLINIC LLC
NPI 1417034745
Nurse Practitioner - Family in Dallas, TX
About South Loop 12 Medical Clinic Llc NPPES
Official registry information on file with the National Plan and Provider Enumeration System.
SOUTH LOOP 12 MEDICAL CLINIC LLC (NPI 1417034745) is a healthcare organization registered as a family in Dallas, Texas and active in the NPI registry since November 2006. The organization holds a CLIA Waiver certificate valid through February 10, 2028 and lists Connie Frances Nellum, Family Nurse Pactitione Certified, as its authorized official.
NPPES Registry Identity
Specialties & Licenses
Other Identifiers 7
Group Practice 1
Accepted Insurance
Medicare Participation & PECOS CMS
Medicare enrollment, revalidation and the clinicians who bill Medicare through this organization, from CMS.
Medicare Enrollment Status
Enrolled in Medicare (PECOS)
South Loop 12 Medical Clinic Llc is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).
Medicare Revalidation Due Date
Revalidation due by February 28, 2027
Medicare-enrolled providers and suppliers confirm their enrollment information with CMS on a set cycle, every 5 years for most and every 3 years for medical equipment suppliers. CMS sets the due date for each enrollment.
Clinicians Billing Medicare Through This Organization
Medicare enrollment records show 1 clinician reassigns Medicare billing to South Loop 12 Medical Clinic LLC, which bills Medicare for the services this clinician delivers.
Clinician (1)
Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
CLIA Laboratory Certificates CMS CLIA
Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.
Certificate of Waiver 45D1022305
South Loop 12 Medical Clinic · Dallas, TXFrequently Asked Questions NPPES & CMS
Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.
What is South Loop 12 Medical Clinic LLC's NPI number?
The NPI number for South Loop 12 Medical Clinic LLC is 1417034745. It was assigned to this organization in the NPPES registry on November 1, 2006.
Where is South Loop 12 Medical Clinic LLC located?
South Loop 12 Medical Clinic LLC is located at 3232 Great Trinity Forest Way Ste. 102, Dallas, TX 75216. The listed phone number is (214) 398-4157.
What is South Loop 12 Medical Clinic LLC's specialty?
The primary specialty registered for this NPI is Nurse Practitioner, specializing in Family, with taxonomy code 363LF0000X.
Is South Loop 12 Medical Clinic LLC enrolled in Medicare?
Yes. South Loop 12 Medical Clinic LLC is registered in the Medicare PECOS enrollment system.
When is South Loop 12 Medical Clinic LLC's Medicare revalidation due?
According to the CMS Revalidation Due Date List (October 2026 release), the Medicare Non-DME Part B enrollment for this organization (Texas, Clinic/Group Practice) is due for revalidation by February 28, 2027. Medicare providers and suppliers revalidate their enrollment every 5 years, and medical equipment suppliers every 3 years. Confirm current requirements with your Medicare Administrative Contractor.
How many clinicians bill Medicare through South Loop 12 Medical Clinic LLC?
According to the CMS Revalidation Reassignment List (October 2026 release), 1 clinician (Nurse Practitioner) reassigns their Medicare billing to South Loop 12 Medical Clinic LLC. A reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for the clinician's services. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
Does South Loop 12 Medical Clinic LLC hold a CLIA laboratory certificate?
Yes. A Certificate of Waiver (number 45D1022305) is associated with this NPI, valid through February 10, 2028. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.
What insurance does South Loop 12 Medical Clinic LLC accept?
Health plans from Molina Healthcare list South Loop 12 Medical Clinic LLC as in-network in at least one marketplace plan. Coverage varies by plan and year; verify with the insurer or the provider before a visit.
When was this NPI record last updated?
The NPPES record for South Loop 12 Medical Clinic LLC was last updated on October 9, 2014. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 12 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.
# South Loop 12 Medical Clinic Llc · NPI 1417034745
Family organization in Dallas, Texas. Organization record, active in the CMS NPPES registry since November 1, 2006.
## Identity
- **NPI:** 1417034745 (Entity type: Organization)
- **Enumerated:** November 1, 2006
- **Primary specialty:** Nurse Practitioner - Family · taxonomy 363LF0000X
- **Organization subpart:** No
- **Authorized official:** Connie Nellum, FAMILY NURSE PACTITIONE CERTIFIED
## Practice location
- **Address:** 3232 GREAT TRINITY FOREST WAY, STE. 102, Dallas, TX 75216-7732
- **Phone:** (214) 398-4157 · **Fax:** (214) 398-4326
## Medicare
- **Medicare:** Enrolled in Medicare (PECOS)
- **Medicare revalidation due:** February 28, 2027 (Non-DME Part B, Texas, Clinic/Group Practice) · CMS Revalidation Due Date List, October 2026 release
- **Clinicians billing through this organization:** 1 clinician (Nurse Practitioner) reassigns Medicare billing to this organization (form CMS-855R) · CMS Revalidation Reassignment List, October 2026 release
## Record status
- **NPPES last updated:** October 9, 2014
- **Other identifiers:** Other 5608640 (TX); Other 8N8001 (TX); Medicare UPIN 16541 (TX); and 4 more
- **CLIA laboratory certificates:** 1 on file
---
Source: [NPI Profile](https://npiprofile.com/npi/1417034745) · Data from the CMS NPPES public registry.