Basic Information
| Provider Information | |||||||||
| NPI: | 1154419612 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACK COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAITH COMMUNITY HOSPITAL AMB SURG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 CHISHOLM TRL | ||||||||
| Address2: | |||||||||
| City: | JACKSBORO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764581403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405676633 | ||||||||
| FaxNumber: | 9405672895 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 CHISHOLM TRL | ||||||||
| Address2: | |||||||||
| City: | JACKSBORO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764581403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405676633 | ||||||||
| FaxNumber: | 9405672895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9405676633 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 119874903 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 119874903 | 05 | TX | MEDICAID |