Basic Information
Provider Information
NPI: 1386770147
EntityType: 2
ReplacementNPI:  
OrganizationName: AMISTAD COMMUNITY HEALTH CENTER, INCORPORATED
LastName:  
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Credential:  
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Mailing Information
Address1: 1533 S BROWNLEE BLVD STE 100
Address2:  
City: CORPUS CHRISTI
State: TX
PostalCode: 784043131
CountryCode: US
TelephoneNumber: 3618442242
FaxNumber: 3618442243
Practice Location
Address1: 1533 S. BROWNLEE BLVD.
Address2: STE. 100
City: CORPUS CHRISTI
State: TX
PostalCode: 784043131
CountryCode: US
TelephoneNumber: 3618842242
FaxNumber: 3618842243
Other Information
ProviderEnumerationDate: 02/26/2007
LastUpdateDate: 08/18/2014
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: FLORES
AuthorizedOfficialFirstName: JOE
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: C.E.O.
AuthorizedOfficialTelephone: 3618842242
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
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NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 
261QF0400X  Y Ambulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)

ID Information
IDTypeStateIssuerDescription
19109940105TX MEDICAID
21507160101TXMEDICAID TPI MULTISPECIALTY - GROUPOTHER


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