Basic Information
| Provider Information | |||||||||
| NPI: | 1215438601 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FANNIN COUNTY HOSPITAL AUTORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PARIS TOTAL FOOT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 504 LIPSCOMB ST | ||||||||
| Address2: | |||||||||
| City: | BONHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754184028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035838585 | ||||||||
| FaxNumber: | 9036407600 | ||||||||
| Practice Location | |||||||||
| Address1: | 580 DESHONG DR | ||||||||
| Address2: | |||||||||
| City: | PARIS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754609318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037065035 | ||||||||
| FaxNumber: | 9037065036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2018 | ||||||||
| LastUpdateDate: | 02/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | CAMP | ||||||||
| AuthorizedOfficialFirstName: | TIFFANY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, QUALITY | ||||||||
| AuthorizedOfficialTelephone: | 9036407301 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FANNIN COUNTY HOSPITAL AUTHORITY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1 | 01 | NONE | OTHER |