1811121387 NPI number — EAST TEXAS FAMILY HEALTHCARE PLLC

Table of content: (NPI 1811121387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811121387 NPI number — EAST TEXAS FAMILY HEALTHCARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS FAMILY HEALTHCARE PLLC
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:
6
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:
1811121387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1273 S PEACHTREE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JASPER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75951-4915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-283-5556
Provider Business Mailing Address Fax Number:
409-283-5557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
920 N. MAGNOLIA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75979-4519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-283-5556
Provider Business Practice Location Address Fax Number:
409-283-5557
Provider Enumeration Date:
05/12/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BUTTERS
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
409-384-9200

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  L0429 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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