Basic Information
| Provider Information | |||||||||
| NPI: | 1487833729 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ATASCOSA HEALTH CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WILSON COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 W OAKLAWN RD | ||||||||
| Address2: | |||||||||
| City: | PLEASANTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780644033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8305698940 | ||||||||
| FaxNumber: | 8305698320 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 10TH ST | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | FLORESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781143167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8303939390 | ||||||||
| FaxNumber: | 8303939399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2007 | ||||||||
| LastUpdateDate: | 09/04/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMALL | ||||||||
| AuthorizedOfficialFirstName: | MONTY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8305698940 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ATASCOSA HEALTH CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CMPE | ||||||||
| NPICertificationDate: | 09/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.