Basic Information
| Provider Information | |||||||||
| NPI: | 1235454828 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLLOM & CARNEY CLINIC ASSOCIATION | ||||||||
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| OtherOrganizationName: | COLLOM & CARNEY CLINIC SLEEP DISORDER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2931 RICHMOND RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755032125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036143200 | ||||||||
| FaxNumber: | 9038387551 | ||||||||
| Practice Location | |||||||||
| Address1: | 5002 COWHORN CREEK RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755039766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036143000 | ||||||||
| FaxNumber: | 9036143525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2010 | ||||||||
| LastUpdateDate: | 10/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | DWIGHT | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9036143282 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLLOM & CARNEY CLINIC ASSOCIATION | ||||||||
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| AuthorizedOfficialCredential: | MHS, CCS-P, CMPE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
No ID Information.