Basic Information
| Provider Information | |||||||||
| NPI: | 1538303011 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY ACTION CORPORATION OF SOUTH TEXAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1820 | ||||||||
| Address2: | |||||||||
| City: | ALICE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783331820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616640145 | ||||||||
| FaxNumber: | 3616642248 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 S ST MARYS ST | ||||||||
| Address2: | |||||||||
| City: | FALFURRIAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783555037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616640145 | ||||||||
| FaxNumber: | 3616642248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2009 | ||||||||
| LastUpdateDate: | 02/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | TREVINO | ||||||||
| AuthorizedOfficialFirstName: | RAFAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DRIECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3616640145 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY ACTION CORPORATION OF SOUTH TEXAS | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | L5201 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00QW12 | 01 | TX | UNSPECIFIIED ID- TYPE MEDICARE | OTHER | 205224301 | 05 | TX | MEDICAID |