1255598876 NPI number — CENTRAL TEXAS COMMUNITY HEALTH CENTERS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255598876 NPI number — CENTRAL TEXAS COMMUNITY HEALTH CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL TEXAS COMMUNITY HEALTH CENTERS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COMMUNITYCARE CENTRAL PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255598876
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 17366
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78760-7366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-978-9009
Provider Business Mailing Address Fax Number:
512-901-9713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2901 MONTOPOLIS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78741-6411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-978-9011
Provider Business Practice Location Address Fax Number:
512-901-9749
Provider Enumeration Date:
05/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KONECNY
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
Authorized Official Title or Position:
INTERIM CEO/PRESIDENT & CFO
Authorized Official Telephone Number:
512-978-9038

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 26469 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2117603 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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