Basic Information
| Provider Information | |||||||||
| NPI: | 1205325222 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL TEXAS COMMUNITY HEALTH CENTERS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITYCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17366 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787607366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129789009 | ||||||||
| FaxNumber: | 5129019713 | ||||||||
| Practice Location | |||||||||
| Address1: | 9301 HOG EYE RD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787244600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129785831 | ||||||||
| FaxNumber: | 5127760462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2018 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MIDDLETON | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGED CARE CONTRACT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5129789427 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | CPCS | ||||||||
| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.