1649412354 NPI number — MT. ENTERPRISE COMMUNITY HEALTH CLINIC

Table of content: (NPI 1649412354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649412354 NPI number — MT. ENTERPRISE COMMUNITY HEALTH CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MT. ENTERPRISE COMMUNITY HEALTH CLINIC
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:
CROSSROADS FAMILY CARE
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:
1649412354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 489
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT ENTERPRISE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75681-0489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-822-3076
Provider Business Mailing Address Fax Number:
903-822-3079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1115 HIGHWAY 259 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-822-3076
Provider Business Practice Location Address Fax Number:
903-822-3079
Provider Enumeration Date:
03/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
903-822-3076

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 203375502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 203375501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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