Basic Information
| Provider Information | |||||||||
| NPI: | 1558311241 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FALLS COMMUNITY HOSPITAL AND CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FCHC BREMOND CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 60 | ||||||||
| Address2: | |||||||||
| City: | MARLIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 766610060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548033561 | ||||||||
| FaxNumber: | 2548836066 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BREMOND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 766295127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548033561 | ||||||||
| FaxNumber: | 2548836066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FORD | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2548033561 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FALLS COMMUNITY HOSPITAL AND CLINIC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 063486701 | 05 | TX | MEDICAID | 458527 | 01 | TX | TPAN | OTHER |