Basic Information
| Provider Information | |||||||||
| NPI: | 1558329797 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST TEXAS BORDER HEALTH CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GENESIS PRIME CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1326 | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756711326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039273782 | ||||||||
| FaxNumber: | 9039271764 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 LINDSEY DR | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756705271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039381146 | ||||||||
| FaxNumber: | 9039272434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROADCAP | ||||||||
| AuthorizedOfficialFirstName: | CARLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9039273782 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0089LZ | 01 | TX | BLUECROSS BLUESHIELD | OTHER | 192226201 | 05 | TX | MEDICAID | 174139901 | 05 | TX | MEDICAID |