Basic Information
| Provider Information | |||||||||
| NPI: | 1255087938 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STEPHEN F AUSTIN COMMUNITY HEALTH CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MYCHN SILVERLAKE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 W ADOUE ST | ||||||||
| Address2: | |||||||||
| City: | ALVIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775112718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2818241480 | ||||||||
| FaxNumber: | 2812206407 | ||||||||
| Practice Location | |||||||||
| Address1: | 9430 BROADWAY ST STE 120 | ||||||||
| Address2: | |||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775848075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2818241480 | ||||||||
| FaxNumber: | 2812206407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2022 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | BRANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 2818241480 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STEPHEN F AUSTIN COMMUNITY HEALTH CENTER, INC | ||||||||
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| NPICertificationDate: | 03/03/2022 | ||||||||
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.