Basic Information
| Provider Information | |||||||||
| NPI: | 1396904686 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH CENTERS OF SOUTH CENTRAL TEXAS, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LULING COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1890 | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786291390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306726511 | ||||||||
| FaxNumber: | 8306726430 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S. LAUREL AVENUE | ||||||||
| Address2: | |||||||||
| City: | LULING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786482624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308756399 | ||||||||
| FaxNumber: | 8308756398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2008 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | DE LA PAZ | ||||||||
| AuthorizedOfficialFirstName: | RAFAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8306726511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HEALTH CENTERS OF SOUTH CENTRAL INC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0005X | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Family Planning Facility | 261QF0050X | N | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 083010101 | 05 | TX | MEDICAID | 00HE62 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 121440502 | 05 | TX | MEDICAID | 121440505 | 05 | TX | MEDICAID |