Basic Information
| Provider Information | |||||||||
| NPI: | 1063529642 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY ACTION CORPORATION OF SOUTH TEXAS | ||||||||
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| OtherOrganizationName: | COMMUNITY ACTION HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | ALICE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783324822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3613960370 | ||||||||
| FaxNumber: | 3616642248 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 FLOURNOY RD STE 2A | ||||||||
| Address2: | |||||||||
| City: | ALICE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783324088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616641417 | ||||||||
| FaxNumber: | 3616643218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 09/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | AWALT | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3616640145 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2-5347 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 1223G0001X | 16588 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 207Q00000X | L5201 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | E5193 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | PA02621 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | 251321 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 190685101 | 05 | TX | MEDICAID | 171353905 | 05 | TX | MEDICAID | 171353901 | 05 | TX | MEDICAID | 171353904 | 05 | TX | MEDICAID | 084609901 | 05 | TX | MEDICAID | 171353903 | 05 | TX | MEDICAID |