Basic Information
| Provider Information | |||||||||
| NPI: | 1073820023 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL TEXAS COMMUNITY HEALTH CENTERS | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITYCARE--BEN WHITE DENTAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17366 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787607366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129789000 | ||||||||
| FaxNumber: | 5129789001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 W BEN WHITE BLVD | ||||||||
| Address2: | STE.112B | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787046888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129789700 | ||||||||
| FaxNumber: | 5129789701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2010 | ||||||||
| LastUpdateDate: | 08/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | KONECNY | ||||||||
| AuthorizedOfficialFirstName: | CAROLYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5129789000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTRAL TEXAS COMMUNITY HEALTH CENTERS | ||||||||
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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 | 2191397-01 | 05 | TX | MEDICAID |