1730450446 NPI number — PETERSON COMMUNITY CARE CLINIC

Table of content: (NPI 1730450446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730450446 NPI number — PETERSON COMMUNITY CARE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETERSON COMMUNITY CARE 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:
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:
1730450446
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
551 HILL COUNTRY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KERRVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78028-6085
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-896-4200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1740 JUNCTION HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERRVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78028-9401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-258-7900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MEDOVICH
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
830-258-7632

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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