Basic Information
| Provider Information | |||||||||
| NPI: | 1528030285 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRISTUS HEALTH SOUTHEAST TEXAS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHRISTUS SOUTHEAST TEXAS - FAMILY PRACTICE CENTER JASPER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 848060 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752848060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007567999 | ||||||||
| FaxNumber: | 4692821999 | ||||||||
| Practice Location | |||||||||
| Address1: | 1276 S PEACHTREE ST | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759514916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4093845701 | ||||||||
| FaxNumber: | 4093844238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 10/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TREVINO | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
| AuthorizedOfficialTelephone: | 4098997102 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHRISTUS HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 137305204 | 05 | TX | MEDICAID |