Basic Information
| Provider Information | |||||||||
| NPI: | 1558434894 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTH AND HUMAN SERVICES COMMISSION | ||||||||
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| OtherOrganizationName: | RIO GRANDE STATE CENTER STHCS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4110 GUADALUPE ST | ||||||||
| Address2: | HOSPITAL REVENUE MGMT.-MC2023 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787514223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122065011 | ||||||||
| FaxNumber: | 5122065302 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 S RANGERVILLE RD | ||||||||
| Address2: | (CLINIC) | ||||||||
| City: | HARLINGEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785527610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9564258900 | ||||||||
| FaxNumber: | 2105318172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 08/25/2017 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ACCOUNTANT III | ||||||||
| AuthorizedOfficialTelephone: | 5122065284 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 0212193-04 | 05 | TX | MEDICAID | 0212193-05 | 05 | TX | MEDICAID |