Basic Information
Provider Information
NPI: 1265460745
EntityType: 2
ReplacementNPI:  
OrganizationName: CENTRAL TEXAS COMMUNITY HEALTH CENTERS
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: COMMUNITYCARE
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4614 N IH 35
Address2:  
City: AUSTIN
State: TX
PostalCode: 787513401
CountryCode: US
TelephoneNumber: 5129789139
FaxNumber: 5129789141
Practice Location
Address1: 4614 N IH 35
Address2:  
City: AUSTIN
State: TX
PostalCode: 787513401
CountryCode: US
TelephoneNumber: 5129789100
FaxNumber: 5129019751
Other Information
ProviderEnumerationDate: 06/30/2006
LastUpdateDate: 09/22/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MIDDLETON
AuthorizedOfficialFirstName: KIMBERLY
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: MANAGED CARE CONTRACT MANAGER
AuthorizedOfficialTelephone: 5129789427
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: CPCS
NPICertificationDate: 09/22/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QF0400X  Y Ambulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)

ID Information
IDTypeStateIssuerDescription
2046666-0105TX MEDICAID
209754901 PKOTHER


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