Basic Information
Provider Information | |||||||||
NPI: | 1194777540 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FALLS COMMUNITY HOSPITAL AND CLINIC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FCHC ROSEBUD CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 60 | ||||||||
Address2: |   | ||||||||
City: | MARLIN | ||||||||
State: | TX | ||||||||
PostalCode: | 766610060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2548033561 | ||||||||
FaxNumber: | 2548836066 | ||||||||
Practice Location | |||||||||
Address1: | 312 N STALLWORTH | ||||||||
Address2: |   | ||||||||
City: | ROSEBUD | ||||||||
State: | TX | ||||||||
PostalCode: | 765702254 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2548033561 | ||||||||
FaxNumber: | 2548836066 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2006 | ||||||||
LastUpdateDate: | 06/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FORD | ||||||||
AuthorizedOfficialFirstName: | JESSICA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | INTERIM ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 2548033561 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FALLS COMMUNITY HOSPITAL AND CLINC | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 458870 | 01 | TX | PTAN | OTHER |