1811485055 NPI number — EAST TEXAS BORDER HEALTH CLINIC

Table of content: (NPI 1811485055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811485055 NPI number — EAST TEXAS BORDER HEALTH CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS BORDER 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:
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:
1811485055
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1326
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARSHALL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75671-1326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-927-3782
Provider Business Mailing Address Fax Number:
903-927-1764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
815 S WASHINGTON AVE STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARSHALL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75670-5341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-927-6850
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2018

Additional Information

Authorized Official

Authorized Official Last Name:
ENGEL
Authorized Official First Name:
TRACEY
Authorized Official Middle Name:
Authorized Official Title or Position:
ENROLLMENT SPECIALIST
Authorized Official Telephone Number:
903-927-3782

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: PENDING , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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