Basic Information
| Provider Information | |||||||||
| NPI: | 1164868998 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY ACTION CORPORATION OF SOUTH TEXAS | ||||||||
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| OtherOrganizationName: | COMMUNITY ACTION HEALTH CENTER KLEBERG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | ALICE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783324822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616640145 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1311 GENERAL CAVAZOS BLVD | ||||||||
| Address2: | SUITES 303 AND C | ||||||||
| City: | KINGSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783637150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615923237 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2013 | ||||||||
| LastUpdateDate: | 09/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | AWALT | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | IEXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3616640145 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY ACTION CORPORATION OF SOUTH TEXAS | ||||||||
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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 | 171353904 | 05 | TX | MEDICAID |