Basic Information
| Provider Information | |||||||||
| NPI: | 1245995521 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMISTAD COMMUNITY HEALTH CENTER, INCORPORATED | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1533 S BROWNLEE BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784043131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618842242 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1711 W WHEELER AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | ARANSAS PASS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783364536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618863025 | ||||||||
| FaxNumber: | 3618842243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2021 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEVOS | ||||||||
| AuthorizedOfficialFirstName: | CAROLE | ||||||||
| AuthorizedOfficialMiddleName: | DIANE | ||||||||
| AuthorizedOfficialTitleorPosition: | ACCESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5126924010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | 11/02/2021 | ||||||||
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 | PENDING | 05 | TX | MEDICAID |