Basic Information
Provider Information | |||||||||
NPI: | 1033440243 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTH TEXAS RURAL HEALTH SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 599 | ||||||||
Address2: |   | ||||||||
City: | COTULLA | ||||||||
State: | TX | ||||||||
PostalCode: | 780140599 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8308793047 | ||||||||
FaxNumber: | 8308792940 | ||||||||
Practice Location | |||||||||
Address1: | 150 MEDICAL DR | ||||||||
Address2: |   | ||||||||
City: | PEARSALL | ||||||||
State: | TX | ||||||||
PostalCode: | 780616624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8308793047 | ||||||||
FaxNumber: | 8308792940 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/28/2010 | ||||||||
LastUpdateDate: | 02/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ZAMORA | ||||||||
AuthorizedOfficialFirstName: | ALFREDO | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8308793047 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 0190506-01 | 05 | TX |   | MEDICAID |