Basic Information
| Provider Information | |||||||||
| NPI: | 1063894855 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH CENTERS OF SOUTH CENTRAL TEXAS INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LOCKHART FAMILY PRACTICE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1890 | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786291390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306726511 | ||||||||
| FaxNumber: | 8306726430 | ||||||||
| Practice Location | |||||||||
| Address1: | 2060 S COLORADO ST | ||||||||
| Address2: | |||||||||
| City: | LOCKHART | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786443951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123989610 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2015 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | DE LA PAZ | ||||||||
| AuthorizedOfficialFirstName: | RAFAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8306726511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HEALTH CENTERS OF SOUTH CENTRAL TEXAS INC. | ||||||||
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| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 355594801 | 05 | TX | MEDICAID |