Basic Information
| Provider Information | |||||||||
| NPI: | 1336265669 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH DEVELOPMENT, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OUR HEALTH - DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 S EVANS ST | ||||||||
| Address2: | |||||||||
| City: | UVALDE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788016034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302785604 | ||||||||
| FaxNumber: | 8302781836 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S EVANS ST | ||||||||
| Address2: | |||||||||
| City: | UVALDE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788015142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302787105 | ||||||||
| FaxNumber: | 8302781836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 05/23/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GONZALES-HANSON | ||||||||
| AuthorizedOfficialFirstName: | RACHEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8302785604 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Z00FM205 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 111438102 | 05 | TX | MEDICAID |