Basic Information
| Provider Information | |||||||||
| NPI: | 1306234521 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEART OF TEXAS COMMUNITY HEALTH CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SANTA FE COMMUNITY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 PROVIDENCE DR | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767072261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543134200 | ||||||||
| FaxNumber: | 2543134531 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 S 25TH ST STE 115 | ||||||||
| Address2: | |||||||||
| City: | TEMPLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765045227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548998650 | ||||||||
| FaxNumber: | 2548998669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2014 | ||||||||
| LastUpdateDate: | 07/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | BALLEW | ||||||||
| AuthorizedOfficialFirstName: | ANNETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2543134282 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 344169301 | 05 | TX | MEDICAID |