1891780656 NPI number — CHINA COMMUNITY CLINIC,LLC

Table of content: (NPI 1891780656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891780656 NPI number — CHINA COMMUNITY CLINIC,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHINA COMMUNITY CLINIC,LLC
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:
Provider Other Organization Name Type Code:
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:
1891780656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 786
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHINA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77613-0786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-752-2301
Provider Business Mailing Address Fax Number:
409-752-2301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 N BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHINA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-752-2301
Provider Business Practice Location Address Fax Number:
409-752-5054
Provider Enumeration Date:
09/16/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
MANAGER/PAC
Authorized Official Telephone Number:
409-752-2301

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  F2352 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 363AM0700X , with the licence number: PA01495 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 8H1480 . This is a "MENDOZA BCBS #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8N3373 . This is a "CHUCK HALL BCBS #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 880660 . This is a "BCBS # CLINIC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0033JQ . This is a "CCC BCBS GROUP #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".